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THE  INTERNATIONAL 

TEXT-BOOK  OF  SURGERY 

BY 

AMERICAN  AND  BRITISH  AUTHORS 

EDITED    BY 

J.  Collins  Warren,  M.D.,  LL.D.,  Hon.  F.  R.C.S.  Eng. 

Professor  of  Surgery  in   Harvard  .Medical  School  ;   Surgeon  to  the  Massa- 
chusetts  (Icneral    Hospital 

\M> 

A.  Pearce  Gould,  M.  S.,  F.  R.  C.  S. 

Surgeon  to  Middlesex    Hospital;     Lecturer  cm   Surgery,   Middlesex   Hospital   Medical   School; 

Member  of  the  Council  and  of  the  Court  of  Examiners  of  the 

Royal   College  of   Surgeons,    England 


Second  EMtion,  TTborougfolY?  IRevteefc 


IN  TWO   VOLUMES 

CONTAINING  977  ILLUSTRATIONS,   INCLUDING 
FULL-PAGE  PLATES   IN   COLORS 


Volume   I 
general  and  operative  surgery 

With   470  Illustrations 


PHILADELPHIA  AND  LONDON 

W.   B.   SAUNDERS  &  COMPANY 

I  Q02 


Copyrighted    August,    1899.     Recopyrighted  January,  1900 
Reprinted  February,  1900,  and  June,  1900. 


Copyright,  1902,  by  W.  B.  SAUNDERS   &   COMPANY 


Registered  at  Stationers'  Hall,  London,  England. 


ELECTROTYPEO    BY  PRESS  OF 

WESTCOTT  &   THOMSON,    PHILADA,  W.    B.    SAUNDERS  &  COMPANY. 


PREFACE  TO  THE  SECOND  EDITION. 


Since  the  publication  of  the  first  edition,  about  two  years  ago, 
surgery  has  progressed  in  almost  every  direction,  and  several  of  the 
chapters  have  needed  extensive  alterations  and  additions  to  bring  them 
up  to  date.  The  entire  book  has  been  carefully  revised,  not  only  by 
the  individual  authors,  but  by  the  editors,  and  special  effort  has  been 
made  to  bring  the  work  down  to  the  present  day.  Since  the  publica- 
tion of  the  first  edition  the  knowledge  in  regard  to  military  and  naval 
surgery,  the  effect  upon  the  human  body  of  various  kinds  of  bullets, 
and  the  results  of  surgery  in  the  field  have  been  largely  added  to 
through  the  Spanish-American  War  and  the  war  in  South  Africa. 
The  chapters  on  Military  and  Naval  Surgery  have  therefore  been 
very  extensively  revised  and  rewritten.  The  chapter  on  Diseases  of 
the  Lymphatic  System  has  been  completely  rewritten  and  brought 
up  to  date.  Of  special  importance  in  this  chapter  is  the  Surgery  of 
the  Spleen.  The  chapter  on  Surgery  of  the  Kidney  has  been  exten- 
sively revised.  Furthermore,  the  addition  of  a  large  number  of  new 
cuts  serves  to  make  the  text  more  lucid. 

The  editors  regret  to  record  the  death  of  two  of  the  original  con- 
tributors, Dr.  Christian   Fenger  and   Dr.  Charles  A.  Siegfried,  U.  S.  X. 

The  editors  desire  to  acknowledge  their  indebtedness  to  Dr.  Farrar 
Cobb,  for  valuable  aid  in  preparing  this  edition  for  the  press. 

J.   COLLINS  WARREN, 
A.    PEARCE  GOULD. 


385378 


PREFACE. 


In  presenting  a  new  work  on  surgery  to  the  medical  profession  the 
editors  feel  that  they  need  offer  no  apology  for  making  an  addition  to 
the  list  of  excellent  works  already  in  existence.  Modern  surgery  is 
still  in  the  transition  stage  of  its  development.  The  art  and  science  of 
surgery  are  advancing  rapidly,  and  the  number  of  workers  is  now  so 
great  and  so  widely  spread  through  the  whole  of  the  civilized  world 
that  there  is  certainly  room  for  another  work  of  reference  which  shall 
be  untrammelled  by  many  of  the  traditions  of  the  past,  and  shall  at 
the  same  time  present  with  due  discrimination  the  results  of  modern 
progress. 

Their  aim  has  been  to  produce  a  reliable  text-book  of  surgery 
embodying  a  clear  but  succinct  statement  of  our  present  knowledge 
of  surgical  pathology,  symptomatology,  and  diagnosis,  and  such  a 
detailed  account  of  treatment  as  to  form  a  reliable  guide  to  modern 
practice.  While  not  aiming  at  the  merely  novel,  they  have  carefully 
omitted  antiquated  methods,  and  they  hope  that  the  reader  will  find  in 
these  pages  only  what  is  practically  useful  to-day. 

The  ever-widening  field  of  surgery  has  been  developed  largely 
by  special  work,  and  this  method  of  progress  has  made  it  practically 
impossible  for  one  man  to  write  authoritatively  on  the  vast  range  of 
subjects  embraced  in  a  modern  text-book  of  surgery.  In  order,  there- 
fore, to  accomplish  their  object,  the  editors  have  sought  the  aid  of 
men  of  wide  experience  and  established  reputation  in  the  various  de- 
partments of  surgery,  and  they  most  gratefully  acknowledge  the  very 
able  assistance  received  from  them.  The  editors  have  endeavored,  by 
means  of  careful  scrutiny  of  the  manuscripts,  to  secure  uniformity  of 
standard  and  teaching. 

The  work   is   so   arranged   that  Volume    I.   is   devoted   chiefly  to 


(j  PREFACE. 

General  Surgery,  and  Volume  II.  to  the  various  branches  of  Special 

Surgery — a  plan  well  adapted  to  the  present  needs  of  both  the  student 

and  the  practitioner. 

It  is  with  deep  regret  that  the  editors  are   obliged   to   record  the 

death  of  one  of  their  contributors,  Dr.  John  B.  Hamilton  of  Chicago. 
The  editors  take  this   opportunity  to  express  their  obligations  to 

Dr.  F.  B.  Lund  of  Boston  for  his  able  assistance  in  the  work  of  editing 

these  volumes. 

J.   COLLINS    WARREN, 
A.  PEARCE   GOULD. 


CONTRIBUTORS  TO  VOLUME  L 


C.   H.  GOLDING    BIRD 
EDWARD    H.   BRADFORD 
J.   G.  A.  BURNS 
HERBERT    L.  BURRELL 
RICHARD    C.   CABOT 
I.  H.   CAMERON 
W.   WATSON    CHEYNE 
J.   CHALMERS    DaCOSTA 

harold  c.  ernst 
george  ryerson  fowler 
george  w.  gay 
robert  b.  greenough 
george  h.  makins 

Deforest 


CHARLES   McBURNEY 
GEORGE    H.   MONKS 
RUSHTON   PARKER 
LEWIS   S.   PILCHER 
FRANZ    PFAFF 
MAURICE    H.  RICHARDSON 
GUY   BELLINGHAM   SMITH 
WALTER   GEORGE   SPENCER 
J.   BLAND   SUTTON 
L.   McLANE   TIFFANY 
WELLER   VAN   HOOK 
JAMES   P.  WARBASSE 
J.   COLLINS  WARREN 
WILLARD 


IO  CONTENTS. 

CHAPTER    VII. 

PAGE 

Erysipelas;   Hospital  Gangrene;  Tetanus 173 

By  J.  Collins  Warren,  M.  D.,  LL.  D.,  Hon.  F.  k.  ('.  s.,  Eng., 

Professor  of  Surgery,  Harvard   Medical  School;   Surgeon  to  the 
Massachusetts  General  Hospital. 

CHAPTER    VIII. 

Hydrophobia;    Anthrax;    Glanders;    Actinomycosis;   Madura= 

Foot;  5nake=Bite ;   Insect=Bite 190 

By  Weller  Van  Hour,  M.  I).,  Professor  of  Surgery  in  the  North- 
western University  Medical  School  and  in  the  Chicago  Poli- 
clinic ;    Surgeon    to    the   Cook   County  and  Wesley   Hospitals. 

CHAPTER    IX. 

Gangrene 213 

By  Walter  George  Spencer,  M.  S.,  F.  R.  C.  S.,  Surgeon  to  the 
Westminster  Hospital,  London. 

CHAPTER    X. 

Surgical  Tuberculosis 240 

By  I.  H.  Cameron,  M.  B.,  Hon.  F.  R.  C.  S.,  Eng.,  Professor  of 
Surgery  and  of  Clinical  Surgery  in  the  University  of  Toronto  ; 
Surgeon  to  the  Toronto  General  Hospital,  St.  Michael's  Hospi- 
tal, the  Victoria  Hospital  for  Sick  Children,  St.  John's  Hospital 
for  Women. 

CHAPTER    XI. 

The  Technic  of  Aseptic  Surgery 269 

By  Charles  McBurney,  M.  D.,  Professor  of  Clinical  Surgery, 
College  of  Physicians  and  Surgeons ;  Consulting  Surgeon  to  the 
New  York  Hospital,  St.  Luke's  Hospital,  and  the  Presbyterian 
Hospital,  New  York  City ;  assisted  by  Howard  D.  Collins, 
M.  D.,  Assistant  Visiting  Surgeon  to  the  New  York  City  Hos- 
pital ;  Assistant  Demonstrator  of  Anatomy,  Columbia  Univer- 
sity;  and  Frank  Oastler,  M.  D.,  Physician  in  Chief,  Good 
Samaritan  Dispensary,  New  York  City. 

CHAPTER    XII. 

Operative  and   Plastic  Surgery      312 

By  J.  Collins  Warren,  M.  D.,  LL.  D.,  Hon.  F.  R.  C.  S.,  Eng., 
Professor  of  Surgery,  Harvard  Medical  School  ;  Surgeon  to  the 
Massachusetts  General  Hospital. 


CONTENTS.  II 

CHAPTER   XIII. 

PACK 

Minor  Surgery 404 

By  John  Chalmers  DaCosta,  M.  D.,  Professor  of  the  Principles 
of  Surgery  and  of  Clinical  Surgery  in  the  Jefferson  Medical  Col- 
lege ;   Surgeon  to  the  Philadelphia  Hospital. 

CHAPTER    XIV. 

Anesthetics  and  Surgical   Anesthesia 439 

By  George  W.  Gay,  A.  M.,  M.  I).,  Senior  Surgeon  to  the  Boston 
City  Hospital  ;  Franz  Pfaff,  M.  D.,  Assistant  Professor  of 
Pharmacology,  Harvard  Medical  School ;  and  T.  G.  A.  Burns, 
M.  R.  C.  S.,  Anesthetist  to  the  Middlesex  Hospital,  London. 

CHAPTER    XV. 

Tumors 466 

By  J.  Bland  Sutton,  F.  R.  C.  S.,  Senior  Assistant  Surgeon,  Mid- 
dlesex Hospital ;  Surgeon  to  the  Chelsea  Hospital  for  Women, 
London. 

CHAPTER    XVI. 

Fractures 505 

By  Lewis  Stephen  Pilcher,  M.  D.,  LL.  D.,  Surgeon  to  the  Meth- 
odist Episcopal  and  the  German  Hospitals  in  Brooklyn  ;  and 
James  P.  Warbasse,  M.  D.,  Assistant  Surgeon  to  the  Methodist 
Episcopal  Hospital,  New  York  City. 

CHAPTER  XVII. 

Injuries  to  the  Joints;   Dislocations 597 

By  George  Henry  Makins,  C.  B.,  F.  R.  C.  S.,  Surgeon  to  St. 
Thomas's  Hospital  ;  Joint  Lecturer  on  Surgery  at  St.  Thomas's 
Hospital  Medical  School,  London. 

CHAPTER  XVIII. 

Dislocations  of  the  Hip 659 

By  J.  Collins  Warren,  M.  D.,  LL.  D.,  Hon.  F.  R.  C.  S.,  Eng., 
Professor  of  Surgery,  Harvard  Medical  School  ;  Surgeon  to  the 
Massachusetts  General  Hospital;  assisted  by  F.  B.  Lund,  M.  D., 
Assistant  Visiting  .Surgeon,  Boston  City  Hospital. 

CHAPTER    XIX. 

Diseases  of  the  Bones 675 

By  William  Watson  Cheyne,  F.  R.  S.,  F.  R.  C.  S.,  Professor 
of  Surgery,  King's  College  ;  Surgeon  to  King's  College  Hospi- 
tal, London. 


1 2  CONTENTS. 

CHAPTER   XX. 

PAl  .1'. 

Diseases  of  the  Joints 702 

By  De  Forest  Willard,  M.  D.,  Clinical  Professor  of  Orthopedic 
Surgery,  University  of  Pennsylvania,  Medical  Department;  Sur- 
geon to  the  Presbyterian  Hospital,  Philadelphia. 

CHAPTER   XXI. 

Diseases  of  Special  Joints   (Orthopedic  Surgery) 723 

By  Rushton  Parker,  M.  B.,  B.  S.,  F.  R.  C.  S.,  Professor  of  Sur- 
gery, University  College ;  Surgeon  to  the  Royal  Infirmary, 
Liverpool. 

CHAPTER  XXII. 

Congenital   Dislocation  of  the  Hip;   Flat=Foot;  Club=Foot  751 

By  E.  H.  Bradford,  M.  D.,  Surgeon  to  the  Children's  Hospital; 
Assistant  Professor  of  Orthopedic  Surgery,  Harvard  Medical 
School,  Boston;  assisted  by  Howard  A.  Lothrop,  A.  M., 
M.  D.,  Assistant  Visiting  Surgeon,  Boston  City  Hospital  and 
Long  Island  Hospital ;  Assistant  in  Surgery,  Harvard  Medical 
School,  Boston. 

CHAPTER   XXIII. 

Surgery  of  the  Muscles,  Tendons,  and  Bursa? 763 

By  George  H.  Monks,  M.  D.,  M.  R.  C.  S.  (Eng.),  Instructor  in 
Clinical  Surgery,  Harvard  Medical  School ;  Assistant  Visiting 
Surgeon,  Boston  City  Hospital. 

CHAPTER  XXIV. 

Cranial  Surgery      784 

By  L.  McLane  Tiffany,  M.  D.,  Professor  of  Surgery,  University 
of  Maryland  ;   Surgeon  to  the  University  Hospital,  Baltimore. 

CHAPTER    XXV. 

Surgery  of  the  Spine 823 

By  C.  H.  Golding  Bird,  M.  B.,  F.  R.  C.  S.,  Surgeon  to  Guy's 
Hospital  ;  and  Guy  Bellingham  Smith,  M.  B.,  B.  S.,  F.  R. 
C.  S.,  Surgical  Registrar  to  Guy's  Hospital,  London. 

CHAPTER   XXVI. 

Surgery  of  the  Peripheral   Nerves 862 

By  Maurice  H.  Richardson,  M.  D.,  Assistant  Professor  of  Clin- 
ical Surgery,  Harvard  Medical  School ;  Surgeon  to  the  Massa- 
chusetts General  Hospital. 


CONTENTS.  1 3 

CHAPTER    XXVII. 

PAGE 

Surgery  of  the  Heart  and  Blood= Vessels 893 

By  Herbert  L.  Burrell,  M.  D.,  Assistant  Professor  of  Surgery, 
Harvard  Medical  School  ;  Surgeon  to  the  Boston  City  Hospital 
and  the  Children's  Hospital. 

CHAPTER   XXVIII. 

Surgery  of  the  Lymphatic  System 922 

By  J.  Collins  Warren,  M.  D.,  LL.  I).,  Hon.  F.  R.  C.  S.,  Eng., 
Professor  of  Surgery,  Harvard  Medical  School  ;  Surgeon  to  the 
Massachusetts  General  Hospital ;  and  Robert  B.  Greenough, 
M.  D.,  Surgeon  to  Out-Patients,  Massachusetts  General  Hospi- 
tal ;  Assistant  in  Surgery,  Harvard  Medical  School,  Boston. 


General  and  Operative  Surgery. 


CHAPTER    I. 
SURGICAL   BACTERIOLOGY. 

A    BRIEF    STATEMENT    OF    THE    ESSENTIALS    IN    SURGICAL 
BACTERIOLOGICAL   PROCESSES. 

General  Principles. —  Before  entering  upon  the  discussion  of  the  technic  to  be 
employed  in  surgical  bacteriological  work,  there  are  a  few  general  considerations  that 
should  be  emphasized.  Of  these,  perhaps  one  of  the  most  important  is  the  fact  that  bac- 
teria of  any  kind,  pathogenic  and  non-pathogenic,  do  not  pass  off  moist  surfaces.  The 
practical  value  of  this  observation  lies  in  the  teaching  that  floors,  tables,  and  furniture  in 
the  operating-room  should  be  cleansed  with  a  moist  towel,  mop,  or  other  utensil,  the  better 
to  prevent  the  rising  and  dissemination  of  dust-particles,  so  often  shown  to  be  the  carriers 
of  the  bacteria. 

Structure  and  Classification. — The  structure  of  the  bacteria  is 
simply  cell-membrane  and  protoplasm,  and  they  are  not  possessed 
of  organs  of  digestion  or  of  generation.  Roughly  speaking,  they 
are  classified,  for  medical  purposes,  as  follows  :  Cells  which  have  all 
diameters  the  same — the  spherical  forms,  or  the  micrococci ;  those 
in  which  one  diameter  is  longer  than  any  of  the  others,  and  at  the 
same  time  not  curved — the  bacilli ;  and  those  in  which  one  diameter 
is  longer  than  the  others,  and  is  more  or  less  sharply  curved — the 
spirilla.  (This  grouping  is,  of  course,  of  the  roughest,  from  a  botan- 
ical point  of  view.)  The  development  of  the  bacteria  occurs  in  two 
ways :  by  transverse  subdivision  in  one  or  more  planes  at  the  same 
time,  and  by  spore-formation.  The  micrococci  develop  by  transverse 
subdivision  in  one  or  more  directions  ;  if  in  one  plane  only,  and  if 
there  is  an  incomplete  separation  of  the  two  daughter-cells,  a  diplo- 
coccus  is  formed,  and  if  this  growth  and  incomplete  separation  con- 
tinue in  the  same  plane,  a  chain  is  produced — a  streptococcus ;  if  not 
in  the  same  plane,  but  in  irregular  planes,  a  zooglea  mass  is  formed, 
whilst  if  the  separation  is  complete,  there  results  the  grouping  of  the 
staphylococcus.  If  the  development  is  in  two  planes  at  right  angles  to 
each  other,  four  cells  are  produced  from  one  mother-cell — a  method 
of  development  of  which  the  M.  tetragenus  is  an  example ;  and  if  this 
growth  takes  place  in  three  planes  at  the  same  time,  when  incomplete 
separation  occurs,  as  is  usually  the  case,  the  sarcina  is  the  result.  The 
development  of  the  bacilli  is  similar  so  far  as  it  goes  ;  that  is  to  say, 
it  occurs  by  transverse  subdivision.  Now,  this  subdivision  is  in  one 
direction  only,  and  that  never  in  the  line  of  the  length  of  the  rod. 
Subdivision,  however,  is  not  the  only  method  of  development  of  the 
bacilli.  In  certain  conditions,  usually  those  unfavorable  to  rapid 
growth,  certain  highly  refractive  bodies  make  their  appearance,  usually 
at  the  poles  or  the  center  of  the  rod,  which  then  may  disappear  entirely, 
leaving  only  these  highly  refractive  and  generally  oval-shaped  bodies, 
which  are  extremely  resistant  to  destructive  agencies.     These  bodies 

17 


1 8  INTER  NATIONAL    TEXT-BOOK  OF  SURGERY. 

are  "spores,  and  form  the  resting  and  resisting  stage  of  the  develop- 
ment of  many  bacilli. 

Whether  the  surgeon  has  to  do  with  a  process  set  up  by  a  spore- 
bearing  or  a  non-spore-bearing  micro-organism  may  often  be  a  matter 
of  practical  importance,  as  influencing  the  adaptation  of  means  to  an 
end  in  the  measures  necessary  for  securing  sterilization  of  the  field  of 
operation  or  the  secretions  and  material  obtained  from  it.  Spore-pro- 
duction has  not  been  observed  with  certainty  among  the  micrococci  or 
among  the  spirilla — certainly  not  among  the  varieties  that  are  suf- 
ficiently common  in  surgical  affections  to  make  them  factors  that  must 
be  reckoned  with. 

Lastly,  the  spirilla  develop,  so  far  as  is  known,  by  transverse  sub- 
division only,  and  this  division  of  the  mother-cell  occurs  at  the  junc- 
tion of  two  curves  only,  so  that  the  young  cells  of  the  class  of  the 
spirilla  often  present  the  appearance  of  short  curved  rods — an  appear- 
ance which  very  quickly  disappears  under  favorable  conditions  of 
growth. 

These  conditions  of  growth  are  to  be  considered  under  food-supply, 
temperature,  light,  moisture,  and  gaseous  surroundings. 

The  food-supply  is  obtained  by  the  bacteria  by  the  breaking  up  of 
the  extremely  complex  organic  substances  that  form  the  bodies  of 
plants  or  animals  dead,  or  which  are  excreted  by  them  while  still  alive. 
Whilst  it  is  true  that  the  artificial  food-supply  of  bacteria  cannot  imi- 
tate at  all  perfectly  that  which  they  find  for  themselves  under  natural 
conditions,  the  adaptability  of  many  varieties  renders  it  more  possible 
to  study  them  under  artificial  conditions  than  would  otherwise  be  the 
case.  In  general,  the  bacteria  require  certain  of  the  albumins  or  car- 
bohydrates for  their  nutrition  ;  and  for  the  study  of  the  pathogenic 
varieties,  the  nearer  their  artificially  prepared  nutrient  material  ap- 
proaches to  that  upon  which  they  naturally  thrive,  the  better  will  be 
the  results.  For  this  reason  preparations  from  fluids  or  tissues  of  the 
animal  body  are  more  advantageous  for  the  study  of  the  bacteria  than 
are  mixtures  that  must  be  made  up  more  or  less  empirically. 

Besides  the  necessity  for  a  supply  of  certain  amounts  of  carbon, 
hydrogen,  nitrogen,  proteins,  etc.,  certain  general  conditions  must  be 
fulfilled  to  permit  the  development  of  the  bacteria,  pathogenic  or  other- 
wise. They  must  have  a  certain  amount  of  moisture  ;  for,  whilst  it  is 
true  that  simple  drying,  even  prolonged  over  a  term  of  years,  does  not 
kill  some  kinds  of  bacteria,  especially  those  that  produce  spores,  it  is 
equally  true  that  no  development  of  these  minute  bodies  will  go  on 
under  a  total  absence  of  moisture.  So,  also,  the  presence  or  absence 
of  certain  gases  has  a  marked  influence  upon  the  growth  of  certain 
kinds  of  bacteria.  In  the  case  of  oxygen  this  influence  is  so  marked 
that  an  attempt  has  been  made  to  draw  a  sharp  line  of  division 
between  the  aerobic  (needing  oxygen)  and  the  anaerobic  (requiring  the 
absence  of  oxygen)  bacteria.  The  latter  division  does  not  include 
many  varieties  that  have  been  studied,  or,  indeed,  whose  existence  has 
been  revealed  to  us  by  our  present  means  of  observation,  especially  in 
surgery.  Some  of  them,  moreover, — for  example,  the  Bacillus  tetani, 
— are  of  great  importance. 

Temperature   is   another   of  the   general   conditions  that   must  be 


SURGICAL   BACTERIOLOGY.  1 9 

reckoned  with  to  secure  proper  conditions  for  the  growth  of  the  bac- 
teria. By  far  the  larger  part  of  them  flourish  well  at  a  temperature  of 
between  200  and  25 °  C. ;  those  that  produce  pathogenic  change  in  liv- 
ing tissue  must  be  able  to  flourish  at  a  higher  degree  of  heat  than  this, 
and  most  of  them  will  grow  best  at  37°-38°  C.  Above  the  highest 
and  below  the  lowest  of  these  limits  practically  no  growth  occurs. 
Some  observations  record  development  of  certain  bacteria  as  high  as 
700  C.  and  as  low  as  50  C,  but  no  indication  of  development  of  any 
••of  the  pathogenic  species  has  been  obtained  at  or  near  either  of  these 
points.  An  important  practical  conclusion  to  be  drawn  from  our 
knowledge  of  the  effect  of  temperature  on  the  vitality  of  the  bacteria  is, 
on  the  one  hand,  that  cold  does  not  destroy  them,  even  when  applied 
under  conditions  entirely  beyond  those  that  occur  in  actual  life.  A 
case  in  point  is  Koch's  experiment  of  placing  the  cholera  spirillum  at 
— 320  C.  without  affecting  its  developing  powers  when  brought  back 
to  normal  conditions.  On  the  other  hand,  a  very  moderate  degree  of 
heat  is  sufficient  to  kill  most  bacteria,  very  few  of  them  being  able  to 
withstand  so  low  a  temperature  as  570  C.  if  applied  for  a  sufficient 
length  of  time  (the  destruction  of  spores  requires  a  much  higher 
degree  of  heat). 

Light  is  another  of  the  general  conditions  that  has  an  influence 
upon  the  growth  of  bacteria,  and  it  has  been  shown  that  the  effect  of 
direct  sunlight  is  very  hurtful  to  the  vitality  of  many  kinds  of  bacteria. 
It  is  certain  that  the  thickness  of  the  medium  in  which  the  bacteria 
are  has  much  to  do  with  the  intensity  of  the  effect  of  sunlight  upon 
them  ;  and  it  is  still  an  open  question  whether  much  of  the  effect  of 
sunlight  be  not  due  to  the  heat  of  the  rays  and  their  drying  effect 
(depriving  the  bacteria  of  moisture).  The  more  recent  investigations 
with  the  Rontgen  rays  give  promise  of  valuable  practical  results. 

The  movements  of  bacteria,  when  they  are  present  at  all,  are  affected 
in  many  ways  :  of  course,  by  extremes  of  heat  and  cold,  which  must 
more  or  less  influence  their  vitality ;  but  of  special  importance  is  the 
chemiotactic  influence  of  certain  salts  and  other  materials,  manifested 
by  an  attracting  or  repellent  action  toward  the  bacterial  cells.  This 
positive  or  negative  chemiotaxis  is  of  the  same  nature  as  that  seen  in 
the  case  of  the  cells  of  the  tissues,  leukocytes  and  others,  in  response 
to   the   irritant  action   of  chemicals,  injuries,  or  even   of  the  bacteria. 

Although  disease  is  all  that  concerns  us  here,  the  bacteria  are  active 
in  many  other  processes.  Properly  looked  at,  disease  is  but  another 
name  for  a  perfectly  normal  function,  the  bacteria  producing  the  disease 
doing  so  simply  because  they  find  in  the  tissues  in  which  they  grow 
the  nutrition  necessary  for  that  growth.  This  nutrition  they  secure  by 
breaking  up  the  complex  materials  of  which  the  tissues  are  composed 
or  upon  which  they  are  fed.  Infectious  diseases  and  their  products  are 
therefore  really  the  waste  results  of  bacterial  growth. 

The  methods  by  which  the  bacteria  produce  their  effect  in  the 
body,  very  briefly  stated,  are  as  follows  : 

It  was  formerly  supposed  that  the  results  seen  in  bacterial  disease 
were  due  entirely  to  the  direct  action  of  the  bacteria  themselves.  This 
position,  however,  very  quickly  became  untenable,  for  innumerable 
phenomena  were  observed  that  were  inexplicable  upon  this  ground,  if 


20 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


the  bacteria  themselves  were  to  be  looked  upon  as  anything  but  accom- 
paniments of  the  disease-process.  Other  explanations  were  therefore 
sought  and  obtained.  The  influence  of  the  bacterial  cell  itself  in  the 
production  of  morbid  phenomena  is  very  slight.  In  a  few  cases  there  is 
an  actual  mechanical  action  exerted  by  the  overwhelming  of  special  locali- 
ties by  masses  of  bacterial  cells,  and  a  resultant  interference  with  the 
function  of  the  part,  or  possibly  a  destruction  due  to  pressure.  This, 
however,  is  not  often  seen.  There  occurs  also  an  absorption  by  the  bac- 
teria of  nutrition  meant  for  the  tissue-cells,  and  in  this  way  a  destruction 
of  these  tissue-cells  that  might  be  spoken  of  as  starvation.     Neither  of 


FlG.  i. — Apparatus  for  using  Chamberland  filter,  with  glass  tube  inverted  over  filter,  act- 
ing by  capillary  attraction,  so  that  the  whole  filtering  surface  may  be  in  use,  as  suggested  by 
Dr.  J.  L.  Goodale,  and  applied  in  the  Bacteriological  Laboratory  of  Harvard  Medical  School. 

these  actions,  however,  is  sufficient  to  explain  by  far  the  vast  majority 
of  the  phenomena  seen  as  the  result  of  bacterial  growth.  The  general 
process  may  be  made  clear  by  the  supposition  that  the  bacteria,  during 
their  development,  take  from  the  complex  compounds  in  their  neigh- 
borhood certain  chemical  elements  that  are  necessary  for  their  own 
nutrition.  Thus  there  are  left  other  elements  in  a  condition  of  unstable 
equilibrium.  These  elements  combine  in  the  ways  necessary  to  satisfy 
this  unstable  condition.  As  a  result  of  this  combination  new  com- 
pounds are  formed,  some  more  simple,  others  more  complex  than  the 
originals.    Among  these  new  compounds  there  occur,  in  many  instances 


5 UR GICA L    BACTERIOLOGY. 


21 


of  bacterial  growth,  some  that  are  extremely  hurtful  to  the  tissues  in 
which  they  are  found.  These  are  the  toxins  of  which  so  much  is  now 
said,  and  it  is  to  these  toxins  and  their  action  upon  the  living  tissues 
that  are  due  most  of  the  harmful  results  that  are  seen  to  follow  bac- 
terial growth. 

The  occurrence  of  variation  among  bacteria  has  been  a  matter  of 
much  discussion.  The  general  conclusion  seems  now  to  be  justifiable 
that  only  minor  variations  occur,  and  that  there  is  a  definite  type  of 
structure  and  of  function  to  which  each  bacterium  tends  to  return. 

Methods  of  Cultivation. — For  a  full  description  of  these  meth- 
ods the  student  must  turn  to  the  larger  text-books. 


Fig.  2. — Chamberland  filter  in  lamp-chimney  for  filtering  small   quantities  of  fluid  (redrawn 

from  Muir  and  Ritchie). 


As  preliminary  to  the  obtaining  of  a  pure  culture,  the  vessels  containing  the  nutrient 
media,  and  these  media  themselves,  must  be  completely  freed  from  any  form  of  bacterium. 
This  is  Sterilization,  and  may  be  secured  by  the  use  of  heat  in  its  various  forms,  by  the 
use  of  chemicals,  and,  in  the  case  of  fluids,  by  filtration. 

Heat  may  be  applied  first  by  direct  exposure  to  the  naked  flame  ;  possible  with  knives, 
scissors,  platinum  wires,  etc.,  and  for  burning  infectious  material.  Second,  by  the  use  of 
heated  air,  as  in  the  case  of  the  hot-air  chamber,  in  which  the  temperature  may  be  raised  to 
a  high  degree  by  the  external  application  of  the  heat ;  this  method  is  applicable  to  the 
sterilization  of  glassware,  instruments,  etc.  Third,  moist  heat,  either  direct  boiling  of  fluids 
in  suitable  vessels  (which  is  not  satisfactory  where  spore-bearing  bacteria  are  to  be  destroyed), 
or  by  the  use  of  steam  under  varying  degrees  of  pressure.  Steam-heat  under  pressure  is 
the  most  effective  means  known  for  the  destruction  of  bacteria.  Its  action  is  distinctly  more 
rapid,  penetrating,  and  certain  than  any  other,  and  for  its  use  many  different  forms  of  appa- 
ratus, all  expensive,  have  been  devised. 

Filtration  through  unglazed  porcelain  (the  Chamberland  filter)  or  through  tubes  of  in- 
fusorial earth  is  employed  as  a  means  for  sterilizing  fluids  whose  composition  is  likely  to  be 
changed  by  the  application  of  heat  ( Figs,  i  and  2).  Moist  heat  is  used  for  the  sterilization 
of  culture-media,  and  for  the  treatment  of  infected  bedding,   clothing,  etc.  which  may  be 


22 


INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 


desired  for  use  again.  Filtration  finds  its  application  in  the  separation  of  bacteria  from 
fluids  in  which  the  products  of  bacterial  growth  are  to  be  submitted  to  further  study. 

Chemicals. — Sterilization  by  the  use  of  chemicals  is  possible  only  in  bacteriological  tech- 
nic,  where  the  instruments  or  glassware  so  treated  may  be  subjected  to  thorough  washing 
before  being  again  used.  But  chemicals  find  an  extremely  useful  place  in  the  sterilization 
of  discharges  of  various  kinds,  instruments,  vessels,  old  dressings,  etc. 

In  all  cases  in  which  it  is  desired  to  secure  sterilization,  and  to  keep  the  objects  sterilized 
free  from  further  contamination  by  living  forms,  means  to  this  end  must  he  taken.  This  is 
almost  universally  found  in  the  closing  of  the  neck  of  the  containing  vessel  with  cotton- 
wool. This  cotton  wool  stopper  is  not  meant  to  act  as  a  cork,  to  prevent  entirely  the  en- 
trance of  air  ;  it  needs  merely  to  be  a  filter,  permitting  free  entrance  of  air,  but  filtering  out 
the  bacteria  and  moulds.  Used  in  this  way,  it  serves  as  a  perfect  protection  against  the 
entrance  of  the  bacteria  ;  at  the  same  time,  it  is  not  a  permanent  protection  against  moulds, 
which  after  a  time  will  grow  down  through  the  interstices  of  the  cotton,  their  spores  finally 
dropping  upon  the  nutrient  medium  below.      This  may  be  guarded  against  by  sprinkling  a 


pIG,  3.— Showing  the  application  of  a  Mariotte's  flask  to  a  hot  filter  for  keeping  the  water  at  a 
constant  level  (devised  by  H.  C.  Ernst). 


few  drops  of  solution  of  corrosive  sublimate  upon  the  upper  surface  of  the  cotton,  and  cov- 
ering the  whole  with  a  rubber  cap,  the  latter  serving  also  to  prevent  the  evaporation  of  the 
moisture  that  would  otherwise  take  place. 

In  general,  sterilization  by  dry  heat  is  completed  by  exposure  for  an  hour  to  a  tempera- 
ture of  1800  C.  Boiling  for  five  minutes  is  sufficient  to  kill  non-spore-bearing  bacteria. 
Steam  at  IOO°  C.  for  one  and  a  half  hours  is  enough  to  sterilize  any  nutrient  medium  ;  but, 
as  gelatin  will  not  stand  this  amount  of  heat  without  losing  its  power  of  solidifying  on  cool- 
ing, intermittent  sterilization — twenty  minutes  at  a  time  on  three  successive  days— Jmust  be 
resorted  to  where  this  material  is  concerned.  Steam  under  pressure  at  1200  C.  (thirty 
pounds)  for  fifteen  minutes  is  sufficient  to  destroy  all  spores  or  bacteria.  The  special  pre- 
cautions to  be  taken  in  this  form  of  sterilization  (with  the  autoclave)  may  be  learned  from 
the  persons  supplying  the  apparatus. 

Nutrient  Media. — The  general  principles  to  be  observed  in  the  preparation  of  these 
media  is  that  they  must  resemble  as  closely  as  possible  those  upon  which  the  bacteria  ordi- 
narily flourish.  By  far  the  most  common  of  the  nutrient  media  employed  is  nutrient  gelatin, 
spoken  of  as  "gelatin."      This  consists  of — 


SURGICAL   BACTERIOL  OG  Y. 


23 


Meat-water, 

Sodium  chlorid, 

Peptone,  dry  (Witte), 

Gelatin  (best  French  gold  label), 


1000  c.c.  ; 

5  gms.  (0.5  per  cent.  )  ; 
10  gms.  (1  per  cent.  )  ; 
100  gms.  (10  per  cent.  ). 


Mix,  warm  until  all  gelatin  is  dissolved,  and  neutralize  carefully  with  a  saturated  solution  of 
sodium  carbonate.  Filter,  while  warm  (Fig.  3),  through  filler-paper,  and  place  in  quanti- 
ties of  about  10  c.c.  in  test-tubes  plugged  with  cotton-wool  and  previously  sterilized  by 
dry  heat  (Fig.  4).  Sterilize  by  subjecting  to  steam  at  1000  C.  for  twenty  minutes  upon 
three  successive  days.  Sometimes  the  mixture  does 
not  come  through  clear  at  first.  This  may  be  due  to 
dirt  in  the  pores  of  the  filter-paper  or  to  incomplete 
neutralization  ;  sometimes,  also,  it  does  not  come 
clear  after  these  points  have  been  looked  after,  when 
it  may  be  cleared  by  adding  the  white  of  one  or  two 
eggs,  heating,  and  refiltering.  Sometimes  the  gela- 
tin becomes  cloudy  after  being  placed  in  the  test- 
tubes.  This  may  be  due  to  a  trace  of  acid  that  is 
left  on  the  sides  of  the  tubes  as  they  come  from  the 
factory.  The  danger  from  this  cause  may  be  abol- 
ished by  thoroughly  washing  the  test-tubes  in  hot 
water  before  using  them. 

Meat-water,  which  is  the  basis  of  many  other 
media  besides  nutrient  gelatin,  is  prepared  as  follows  : 

Finely-chopped  lean  meat,  500  gms.  ; 

Water  (pure,  but  not  of  necessity  distilled),  1000  c.c. 

Mix,  and  let  stand  in  a  cool  place  (in  summer  in  the 
ice-chest)  for  twenty-lour  hours,  stirring  occasionally. 
Strain  through  coarse  cloth  and  under  pressure,  to 
extract  all  the  moisture  possible.  If  the  bulk  is  not 
IOOO  c.c.  of  watery  extract,  add  enough  water  to 
bring  it  up  to  that  amount.  Boil  in  a  water-bath  for 
an  hour;  filter  through  coarse  filter-paper,  from 
this  meat-water  may  be  made  the  nutrient  gelatin 
spoken  of  above,  and  nutrient  bouillon,  which  con- 
sists of — 

Meat-water,  IOOO  c.c.  ; 

Sodium  chlorid,  5  c.c.  (0.5  per  cent.)  ; 

Peptone,  dry  (Witte),    10  c.c.  (1  percent.). 

Mix.  Neutralize  very  carefully  with  a  saturated 
solution  of  sodium  carbonate,  added  drop  by  drop  as 
the  line  is  approached,  until  red  litmus  is  turned 
slightly  blue,  and  blue  litmus  is  not  turned  red  1  to 
avoid  the  amphoteric  reaction).  This  bouillon  may 
be  kept  in  bulk  in  flasks  or  be  placed  in  test-tubes, 
and  sterilized  by  steam  at  1000  C.  for  an  hour  and  a 
half,  or  by  steam  under  pressure. 

For  the  study  of  bacteria  at  the  temperature  of 
the  body  there  is  often  needed  a  medium  that  is  more 
easy  of  preparation  than  blood-serum.  Such  a  me- 
dium is  found  in  nutrient  agar-agar.  This  is  pre- 
pared precisely  as  is  nutrient  gelatin,  excepting  that 

in  the  place  of  the  10  per  cent,  of  gelatin  there  is  added  from  1  to  1.5  per  cent,  of  agar- 
agar.  The  mixture  is  difficult  to  make  clear,  but  this  end  may  be  reached  by  the  addition 
of  the  white  of  an  egg  before  filtering,  or  by  straining  two  or  more  times  through  filter- 
paper.  To  facilitate  filtering,  the  whole  apparatus  may  be  placed  in  the  steam  sterilizer,  or 
in  that  illustrated  in  Fig.  3. 

Glucose  media  are  often  useful  for  special  purposes,  and  are  prepared  by  adding,  usually, 
I  per  cent,  of  glucose  to  the  different  media  already  spoken  of. 

Whilst  these  mixtures  are  necessary  adjuncts  to  the  study  of  the  biological  characteristics 
of  all  bacteria,  certain  of  these  characteristics  are  not  so  well  observed,  and  some  of  them 
are  not  seen  at  all,  unless  a  solid  albuminous  material,  approaching  the  conditions  found  in 
the  tissues,  be  employed.  This  is  in  no  way  so  well  secured  as  by  the  use  of  blood-serum. 
This  furnishes  the  nearest  approach  to  the  elements  found  in  the  living  tissues  for  the  nutri- 
tion of  bacteria,  and  was  first  introduced  by  Koch  for  the  study  of  the  bacillus  of  tuberculosis. 


Fig.  4. — Apparatus    for   filling 
tubes. 


24 


INTERNATIONAL    TEXTBOOK  OF  SURGE  NY. 


The  blood  is  collected  under  us  nearly  as  possible  aseptic  conditions,  is  allowed  to  clot  in  a 
cool  place,  and  in  handling  is  shaken  as  little  as  possible.  At  the  end  of  twenty-four  or 
forty-eight  hours  the  serum  is  drawn  off,  placed  in  sterile  test-tubes,  and  sterilized  al  a 
temperature  of  57°  C.  for  an  hour  each  day  during  six  days.  If  it  be  desired  to  use  the 
.serum  in  its  fluid  condition,  ii  is  now  ready  ;  but  if,  as  is  usually  the  case,  it  is  desired  to  use 
it  as  a  solid  nutrient  medium,  it  may  be  solidified,  after  this  sterilization,  by  being  raised  to 
640  or  66°  C.  for  several  hours  until  it  has  solidified ;  or  it  may  be  solidified  immediate!) 
after  being  placed  in  the  test-tubes  by  being  placed  in  an  Arnold  sterilizer,  in  which  case 
th<  coagulation  and  the  sterilization  may  be  carried  on  at  the  same  time.  This  rapid  coagu- 
lation naturally  makes  the  blood-serum  opaque.  It  may  be  made  to  retain  its  translucency 
by  taking  advantage  of  a  known  physiological  fact,  and  adding,  before  the  sterilization, 
from  j1,,  to  \  of  I  per  cent,  of  a  caustic  alkali — either  sodic  hydrate  or  potassium  hydrate — 
the  amount  to  be  used  depending  upon  the  kind  of  animal  from  which  the  serum  was  drawn. 
The  addition  of  this  amount  of  alkali  will  enable  the  rapid  method  of  sterilization  of  blood- 
serum  to  be  adopted,  and  at  the  same  time  will  give  as  a  result  a  solid  medium  of  a  very 
considerable  degree  of  translucency. 

Blood-serum  may  be  used  plain  or,  as  is  now  very  common,  in  the  form  of  Loner's 
blood-serum  mixture,  consisting,  in  the  original,  of  3  parts  of  calves'  or  lambs'  blood-serum, 
to  which  has  been  added  1  part  of  bouillon  containing  I  per  cent,  of  glucose,  sterilized  as  for 
blood-serum. 

The  difficulties  in  the  way  of  keeping  up  the  virulence  of  the  streptococci  have  led  to 
the  suggestion  of  a  number  of  different  media  for  this  particular  purpose,  and  of  these,  those 
of  Marmorek  seem  to  be  the  best.      His  media  are  made  by  mixing — 

1.  Human  blood-serum  2  parts,  nutrient  bouillon  1  part. 

2.  Pleuritic  or  ascitic  serum  1  part,  bouillon  2  parts. 

3.  Ass-  or  mule-serum  2  parts,  bouillon  1  part. 

4.  Horse-serum  2  parts,  bouillon  1  part. 

Dunham's  peptone  solution,  useful  for  studying  the  indol  reaction,  is  prepared  by  adding 
I  per  cent,  dry  peptone   (the  best  is  Witte's)  and  0.5  per  cent,  sodium  chlorid  to  distilled 
water.      Filter  after  the  solids  are  dissolved,  place   in   sterilized  test- 
er/   \^  tubes,  and  sterilize  by  steam  heat. 

Certain  characteristics  of  bacteria  are  best  shown  upon  starch- 
containing  materials,  and  this  starch-containing-nutrient  medium  is 
best  found  in  sterilized  potato.  The  potatoes  may  be  prepared  for 
use  most  easily  by  cutting  out  cylinders  with  an  ordinary  apple-corer, 
cutting  the  cylinder  into  two  wedge-shaped  portions,  and  placing  them 
in  sterilized  tubes  with  some  form  of  support  ( small  pieces  of  glass 
rod),  below  the  potato,  to  keep  it  from  the  bottom  of  the  tube,  and 
sterilizing    the  whole    for  at  least    an   hour   in    the   steam   sterilizer 

(Fi§-  5)-         . 

Most  material  to  be  studied  bacteriologically  contains  more  than 
one  kind  of  bacterium.  Some  method  for  separating  these  varieties 
must  therefore  be  adopted.  By  far  the  most  common  method  in  use 
is  that  of  plate-culture,  either  according  to  the  original  method  of 
Koch  (using  three  or  more  glass  plates),  or  a  more  common  method 
of  using  three  or  more  shallow  double  dishes,  the  so-called  Petri 
dishes.  A  method  of  making  plate-cultures  is  as  follows  :  Melt 
three  or  more  tubes  of  nutrient  gelatin  ;  introduce  into  the  first  tube 
a  small  quantity  of  the  material  to  be  examined,  and  mix  it  thoroughly 
without  shaking,  so  as  to  prevent  the  formation  of  air-bubbles.  From 
this  first  dilution  transfer  two  platinum  loopfuls  of  the  mixture  to  a  sec- 
ond tube,  and  mix  thoroughly.  From  this  second  tube  transfer  again 
two  loopfuls  to  a  third  tube,  and  mix  thoroughly.  This  dilution  may 
be  carried  further  if  there  is  reason  to  suppose  the  existence  of  a 
large  number  of  bacteria  in  the  original  material,  or  a  number  of 
rapidly  growing  liquefying  bacteria.  The  dilutions  are  then  poured 
so  as  to  be  distributed  evenly  over  the  bottom  of  the  lower  of  the 
Petri  dishes,  are  covered  with  the  upper  one,  the  gelatin  is  allowed 
to  harden,  and  the  cultures  are  set  aside  for  further  observation. 

Esmarch's  roll-cultures  are  made  in  precisely  the  same  way,  so 
far  as  the  mixing  in  the  gelatin  is  concerned  ;  instead,  however,  of 
pouring  the  dilutions  either  upon  glass  plates  or  in  the  Petri  dishes, 
the  tubes  themselves  are  laid  almost  flat  upon  a  piece  of  ice  and  are 
rapidly  revolved.  The  gelatin  mixture  solidifies  upon  the  side  of  the 
tubes  themselves,  and  plate-cultures  are  formed  in  the  tubes.  Plate-cultures  may  be  made 
with  nutrient  agar  as  with  nutrient  gelatin,  except  that  care  must  be  taken  that  the  melted 
agar  is  not  so  hot  as  to  kill  the  bacteria  sought  for.      These  cultures  are  of  value   when  it 


-* 


> 


J, 


Fig.  5. — Test-tube 
with  constriction  at 
bottom  for  supporting 
potato-cultures  above 
the  water  of  conden- 
sation. Instead  of  the 
constriction,  a  small 
marl ile  or  a  piece  of 
glass  tubing  or  rod 
may  be  used. 


SURGICAL    BACTERIOLOGY. 


25 


is  desired  to  study  bacteria  at  the  temperature  of  the  body.  So,  also,  a  separation  of  bac- 
teria may  be  secured  with  a  good  deal  of  accuracy  by  spreading  the  material  to  be  examined 
upon  a  surface  of  nutrient  agar  or  nutrient  blood-serum,  or  upon  the  surface  of  blood-serum 
plates.  This  spreading  is  done  by  dipping  the  platinum  wire  (Fig.  6)  into  the  infected 
material   and  drawing  it,  in  successive  parallel   lines,  over  the   surface  of  the  material   as 


X: 


=cz 


=3L 


J    d 


FlG.  6. — Platinum  wire  swaged  into  brass  wire,  and  reversible  for  transportation  (as 
devised  by  Dr.  ].  11.  McCollom,  and  used  in  the  Bacteriological  Laboratory  of  the  Harvard 
Medical  School),  a.  Closed,  fi.  Open.  c.  The  same  with  end  bent  at  right  angles,  for  picking 
up  colonies  in  test-tube.     d.  The  same  in  operation. 

many  times  as  may  be  possible.  Sometimes  it  is  necessary  to  separate  pathogenic  bac- 
teria by  the  inoculation  of  animals  with  the  mixture  of  bacteria,  and,  when  a  particular 
disease  appears,  obtain  pure  cultures  from  the  tissues  of  the  animal  so  inoculated.  Occa- 
sionally also  the  separation  is  obtained  by  the  killing  of  non-spore-bearing  forms  by  heat. 


FlG.  7. — Kipp's  apparatus  for  producing  hydrogen,  with  wash-bottles  attached. 


Certain  of  the  bacteria  grow  only  in  the  absence  of  oxygen.  In  such  cases  it  is  neces- 
sary to  take  measures  for  the  exclusion  of  the  oxygen.  This  may  be  done  by  substituting 
for  air  an  atmosphere  of  hydrogen — the  common  method  adopted  (Fig.  7)  ;  by  covering  the 
ordinary  needle-culture  in  gelatin  or  agar  with  a  layer  of  sterile  oil  or  an  added  amount  of 
the  same  nutrient  medium  ;  or  by  a  fermentation-tube,  a  modified  form  of  which  is  shown 
below  (Fig.  8). 


26 


/ .  \  •  I  /.  RNATIONAL    TEXT- BO  OK  OF  SUR  GE  R  I . 


Hanging  drop  cultures,  frequently  necessary  for  the  purpose  of  studying  bacteria  alive, 

consist    simply  of  a    cell  slide   over   which    is 


et> 


FlG.  8. — A  method  for  carrying  on  an- 
aerobic cultures  and  measuring  gas-production 
(as  devised  by  Prof.  Theobald  Smith). 


placed  a  cover-glass,  on  the  under  surface 
ol  which  is  suspended  a  drop  of  nutrient 
fluid  containing  some  oi  the  bacteria  it  is 
desired    to    examine. 

The  filtration  of  cultures — that  is,  the 
removal  of  all  bacteria  from  fluids  in  which 
they  have  grown — is  accomplished  by  one 
of  the  many  forms  of  the  ( lhamberland  filter, 
through  tubes  of  unglazecl  porcelain  or  infu- 
sorial earth. 

Cultures  are  usually  observed  at  a  tem- 
perature  of  from  200  to  22°  C,  which  is 
represented  by  the  average  temperature  of 
the  ordinary  room  ;  or  they  are  studied  at 
the  temperature  of  the  body,  which  is  ap- 
proximately 37. 5°  C.  For  the  latter  pur- 
pose a  special  warm  chamber  is  necessary, 
of  which  there  is  a  large  number,  the  gen- 
eral principles  of  them  all  being  the  same. 

The  general  methods  for  the  study  of 
the  bacteria,  so  far  as  they  differ  from  those 
of  ordinary  histological  work,  require,  in  the 
first  place,  a  good  microscope,  which  should 
include  coarse  and  fine  adjustment,  with  a 
homogeneous  immersion  lens,  and  a  sub- 
stage  condenser.  The  bacteria  may  be  ex- 
amined either  stained  or  unstained,  in  cover- 
glass  preparations  and  in  sections.  When 
bacteria  are  examined  unstained,  the  hang- 
ing-drop method  is  useful;  for  stained  preparations  recourse  must  be  had  to  "cover-glass 
preparations."  Perfectly  clean  cover-glasses  are  used,  and  a  minute  portion  of  the  mate- 
rial containing  the  bacteria  is  placed  upon  one  of  them  and  spread  in  as  thin  a  layer  as 
possible,  either  by  means  of  a  platinum  wire,  or  by  placing  a  second  cover-glass  upon  the 
first,  pressing  the  two  together  very  gently,  and  drawing  them  apart  in  as  nearly  as  may  be 
the  same  plane.  The  material  is  allowed  to  dry  in  the  air,  and  the  cover-glasses  are  then 
passed  through  the  flame  of  a  Bunsen  burner  three  times,  so  as  to  fix  the  film  on  the  surface 
of  the  cover-glass  and  prevent  its  being  washed  off.  In  the  case  of  blood  this  fixation  is 
best  accomplished  by  placing  the  cover-glasses  in  a  hot-air  chamber  at  1200  C.  for  an  hour, 
or  by  immersion  in  a  strong  solution  of  corrosive  sublimate  for  two  or  three  minutes  ;  the 
cover-glasses  are  then  washed  and  dried.  Sometimes  also,  if  the  structure  of  the  tissue- 
cell  is  desired,  "corrosive"  films  maybe  substituted  for  the  dry  films.  These  films  are 
prepared  by  placing  them,  while  still  wet,  in  a  saturated  solution  of  perchlorid  of  mercury 
in  0.75  per  cent,  of  sodium  chlorid  for  five  minutes,  then  for  half  an  hour  in  0.75  per  cent, 
sodium-chlorid  solution  to  wash  out  the  corrosive  sublimate  ;  they  are  then  washed  in  alco- 
hol, at  first  dilute,  then  stronger,  a  few  minutes  in  each  ;  after  this  they  may  be  stained  and 
examined  (Muirand  Ritchie). 

For  bacteriological  purposes  tissues  are  best  hardened  in  absolute  alcohol.      The  mate- 
rial  is  cut   into  pieces  from    I  to  2  c.c.  in  size,  and 
-^.  these  are  placed  in  absolute  alcohol,  which  is  to  be 

changed  on  successive  days  three  times  ;  the  tissue 
is  then  ready  for  cutting  with  any  of  the  apparatuses 
for  cutting  sections.  Sections  may  also  be  cut  from 
fresh  material  with  the  freezing  microtome.  Har- 
dened tissues  may  be  fixed  on  blocks  with  a  lew 
drops  of  celloidin  or  with  glycerin  jelly  (Fig.  9). 
In  examining  bacteria  in  the  tissues  the  object  is  to 
secure  sections  as  thin  as  possible,  not  covering 
very  large  areas. 

Staining. — The  staining  of  bacteria  is  almost 
a  science  by  itself,  and  it  has  only  been  since  the 
introduction  of  the  anilin  dyes  that  a  great  advance 
in  our  knowledge  of  the  bacterial  reactions  has 
been  made.  There  are  a  great  number  of  these 
dyes,  but  only  a  few  have  been  generally  adopted  for  ordinary  bacteriological  work.  Of 
these,  there  are  the  two  classes,  the  basic  and  the   acid  dyes.      Of  the  basic  stains,  those 


FlG.  9. — Tissues  for  section-cutting 
mounted  on  fiber  blocks;  stuck  on 
with  celloidin  (as  suggested  by  Dr. 
Henry  Jackson). 


SURGICAL   BACTERIOLOGY.  2J 

most  commonly  employed  are  the  following  :  Gentian  violet,  which  stains  very  rapidly,  and 
easily  over-stains  ;  methyl  violet,  with  the  same  peculiarities  to  a  less  degree  ;  fuchsin, 
which  stains  more  slowly,  does  not  easily  over-stain,  and  is  more  permanent  than  the 
two  others  ;  methylene  blue,  which  stains  more  slowly,  almost  never  over-stains,  and  is 
extremely  lasting  ;  vesuvin,  or  Bismarck  brown,  which  gives  a  brown  stain  that  is  not  used 
much  now.  Its  usefulness  lies  in  the  fact  that  preparations  stained  with  it  are  peculiarly 
well  adapted  to  photography  ;  but  since  the  introduction  of  orthochromatic  plates  the  neces- 
sitv  for  special  staining  of  the  bacteria  for  photography  has  practically  disappeared.  These 
are  the  common  basic  dyes  that  are  employed  in  the  study  of  bacteria.  They  are  pecu- 
liarly fitted  for  the  purpose,  for  the  reason  that  they  have  a  special  affinity  for  the  staining 
of  the  cell-nuclei  of  the  tissues  and  of  the  bacteria. 

The  acid  dyes  commonly  used  are  eosin,  safranin,  and  picric  acid.  These  dyes  are 
employed  for  contrast-stains  because  they  have  an  especial  affinity  for  cell-protoplasm  and 
intercellular  substances,  and  are  spoken  of  as  diffuse  stains.  The  variation  in  anilin  dyes, 
not  only  in  name  but  in  chemical  composition,  makes  it  of  importance  that  different  ob- 
servers should  use  the  same  dye,  and  this  uniformity  of  stains  is  to  be  obtained,  apparentlv, 
only  by  employing  those  prepared  by  Griibler  of  Leipsic.  It  is  to  be  remarked  also  that 
all  anilin  colors  degenerate  more  or  less  rapidly  after  the  original  package  is  opened,  so 
that  it  is  advisable  to  procure  small  amounts  at  a  time,  or  to  keep  opened  packages  in  air- 
tight vessels.  So,  also,  it  is  well  to  remember  that  all  solutions  of  these  dyes  should  be 
freshly  prepared,  saturated  alcoholic  solutions  being  the  only  ones  that  can  be  relied  upon 
to  keep  for  any  length  of  time.  These  saturated  alcoholic  solutions  may  be  used  as  stock 
solutions  from  which  all  the  various  staining  mixtures  may  be  prepared. 

The  first  and  most  generally  used  of  these  staining  mixtures  is  the  dilute  alcoholic  solu- 
tion, consisting  of  I  part  of  the  strong  alcoholic  solution  filtered  into  2  parts  of  distilled 
water. 

The  staining  of  cover-glass  preparations  may  be  accomplished  either  by  floating  the 
cover-glasses  on  the  surface  of  the  fluid  for  a  few  minutes,  or  by  flowing  the  cover-glass 
itself,  held  in  forceps,  with  a  few  drops  of  the  slain.  After  exposure  to  the  reagent  for  a 
few  moments — on  the  average  about  five  minutes — the  cover-glass  is  to  be  thoroughly 
washed,  dried,  and  then  mounted  in  a  drop  of  xylol  balsam.  The  xylol  balsam  must  be 
used  in  bacteriological  work,  for  the  reason  that  other  solvents  of  Canada  balsam  dissolve 
the  coloring  matter  from  the  bacteria  more  than  is  conducive  to  the  best  results. 

Frequently  bacteria  come  under  observation  that  require  special  stains,  but  for  the  gen- 
eral staining  of  cover-glass  preparations  for  the  simple  determination  of  the  presence  or 
absence  of  bacteria  a  saturated  watery  solution  of  methylene  blue  will  be  found  to  be  the 
best  to  begin  with. 

Occasionally  it  is  necessary  to  use  mordants  for  the  purpose  of  more  intensely  staining 
the  bacteria.  The  use  of  mordants  usually  makes  necessary  the  after-employment  of  some 
decolorizing  agent  to  lake  away  the  intense  staining  from  the  tissues  and  leave  the  bacteria 
more  prominent.  The  carbolic  acid  in  the  carbol-fuchsin  mixture  and  the  anilin-oil  mixtures 
are  examples  of  the  use  of  mordants  ;  so  also  are  the  alkalies  used  in  the  preparation  of 
certain  stains  like  caustic  potash  in  the  Loftier' s  solution,  the  use  of  heat,  and  the  prolonged 
application  of  the  ordinary  staining  fluid.  As  decolorizing  agents  the  mineral  acids  are 
the  strongest,  vegetable  acids,  such  as  acetic  acid,  are  next,  alcohol  next,  and  water  last. 
For  sections,  dehydration  and  clearing  are  essential.  Dehydration  is  accomplished  with 
absolute  alcohol,  and  clearing  is  attained  bv  means  of  xylol,  which  is  the  cheapest,  or  by 
oil  of  cedar,  which  is  the  best — not  with  the  ordinary  clearing  reagents,  such  as  oil  of 
cloves,  because  the  latter  decolorizes  too  much  the  specimen  stained  with  the  anilin  colors. 

Of  the  general  methods  u>ed  for  staining,  other  than  the  single  dyes,  a  few  of  the  more 
common  are  these  : 

(1)  Loffler '  s  alkaline  methylene  blue,  which  consists  of  a  saturated  solution  of  methylene 
blue  in  alcohol,  30  parts,  a  solution  of  potassium  hydrate  in  distilled  water  (1  :  10,000) 
100  parts. 

Sections  may  be  stained  in  this  mixture  for  from  fifteen  minutes  to  several  hours  ;  they 
are  then  to  be  decolorized  with  lA  to  1  per  cent,  acetic  acid,  washed  in  water,  dehydrated 
in  alcohol  or  anilin  oil,  cleared  in  xylol,  and  mounted.  Cover-glass  preparations  may  be 
stained  in  from  five  minutes  to  half  an  hour  in  the  cold. 

(2)  Ktihne's  Methylene  Blue. — Methylene  blue  1.5  grams;  absolute  alcohol  10  c.c.; 
carbolic-acid  solution  (1  :  20)  100  c.c.  This  to  be  used,  and  the  decolorization  carried  out 
precisely  as  with  the  preceding  ;  or  the  decolorizing  may  be  accomplished  with  very  dilute 
hydrochloric  acid — 2  to  3  drops  in  a  watch-glassful  of  water. 

(3)  The  anilin-water  mixtures,  consisting  of  a  saturated  alcoholic  solution  of  gentian 
violet,  methyl  violet,  or  fuchsin  10  parts,  absolute  alcohol  11  parts,  anilin-water  100  parts. 
The  anilin-water  is  simply  a  saturated  solution  of  anilin  oil  in  water,  and  is  made  by  shak- 
ing up  about  I  part  of  anilin  oil  to  20  parts  of  water  and  filtering  carefully.  These  anilin- 
water  mixtures  are  unstable,  and  are  to  be  made  fresh  as  often  as  once  in  every  few  days. 


28  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

(4)  Carbol-fucksin  is  prepared  of  basic  fuchsin  1  part,  absolute  alcohol  10  parts,  and 
solution  of  carbolic  acid  (1  :  20)  100  parts.  This  is  a  very  strong  slain,  and  under  ordinary 
conditions  one  hall  to  one  minute  Is  sufficient  for  staining  cover-glasses,  it  is  so  strong  that 
it  does  not  find  any  useful  application  in  the  staining  of  sections. 

Gram's  method  of  staining  is  a  useful  one,  depending  upon  the  decolorizing  action  of 
the  so-called  Gram's  mixture,  consisting  of  resublimated  iodin  1  part,  potassium  iodid  2 
parts,  distilled  water  300  parts.  The  action  of  this  solution  upon  tissues  containing  bacteria 
is  a  special  one,  in  that  it  removes  the  first  stain  from  the  tissues  and  from  some  bacteria,  but 
not  others  ;  so  that,  as  in  the  case  of  the  gonococcus,  this  method  of  staining  furnishes  a  help 
toward  a  differential  diagnosis.  At  the  same  time  the  action  of  the  iodin  solution  upon  the 
bacteria  does  not  seem  to  be  a  true  decolorizing  action,  although  it  is  difficult  to  say  precisely 
what  it  is. 

A  method  of  applying  Gram's  method  is  to  stain  the  preparation  in  the  anilin-oil  gentian- 
violet  mixture  for  about  five  minutes,  and  wash  in  water  ;  then  transfer  to  Gram's  solution 
until  the  color  becomes  a  purplish  black  (generally  from  thirty  seconds  to  a  minute  is  suffi- 
cient); decolorize  with  absolute  alcohol  until  the  black  color  has  entirely  disappeared  and 
the  preparation  is  at  the  most  of  a  very  light  violet  color;  dehydrate  completely;  clear; 
then  mount.  Of  course,  in  the  case  of  cover-glass  preparations  the  specimen  is  merely 
washed  in  water,  dried,  and  mounted. 

Spore-staining. — Sometimes  it  is  of  advantage  to  stain  spores  that  under  ordinary  condi- 
tions do  not  take  the  coloring  matter.  An  effective  method  is  first  to  use  the  carbol -fuchsin 
stain,  heating  over  the  flame  of  a  Bunsen  burner  for  from  fifteen  to  twenty  minutes  ;  then 
decolorize  with  I  per  cent,  sulphuric  acid  in  water  for  a  few  seconds  only  ;  wash  in  water ; 
contrast  stain  with  saturated  watery  methylene  blue  for  15  to  30  seconds  ;  wash  carefully  in 
water  ;  dry  and  mount. 

The  staining  of  flagella  is  difficult,  but  as  this  has  also  been  used  for  purposes  of  differen- 
tial diagnosis,  a  brief  statement  of  the  method  may  not  be  inappropriate  here. 

The  first  and  best  method  is  that  of  Loftier.  In  all  cases  twenty-four-hour  cultures  upon 
agar  should  be  used  ;  the  cover-glass  should  be  thoroughly  cleaned  before  use  ;  and  the 
preparation  upon  the  cover-glass  should  consist  of  the  minutest  possible  portion  of  the  cul- 
ture, diluted  as  much  as  may  be  in  a  drop  of  water. 

Loftier' s  method  is  as  follows  :  There  must  be  two  solutions. 

a.  The  mordant.  Add  to  10  c.c.  of  a  20  per  cent,  solution  of  tannin  in  water  as  many 
drops  of  a  saturated  solution  of  ferrous  sulphate  in  wrater  as  will  give  the  whole  fluid  a  dark 
violet  tint.  To  this  add  3  to  4  c.c.  of  a  solution  made  by  boiling  1  gram  of  logwood  with 
8  c.c.  of  water  (after  boiling,  filter  and  add  enough  water  to  bring  up  to  9  c.c).  The  mix- 
ture of  the  tannin  solution  with  the  logwood  solution  is  of  a  dirty,  dark  violet  color,  and 
if  too  much  logwood  solution  be  added,  particles  are  precipitated  which  make  the  fluid  use- 
less as  a  mordant.  This  mordant  should  be  made  fresh  each  time  it  is  used,  although  the 
addition  of  4  to  5  c.c.  of  a  I  :  20  carbolic-acid  solution  makes  it  more  stable  without  injuring 
its  properties. 

b.  The  stain.  To  loo  c.c.  of  a  filtered  saturated  solution  of  anilin  oil  in  water,  add 
I  c.c.  of  a  I  per  cent,  solution  of  sodic  hydrate,  which  makes  the  mixture  faintly  alkaline. 
To  this  add  4  to  5  grams  of  methyl  violet,  methylene  blue,  or  fuchsin-crystals,  and  shake 
thoroughly. 

When  a  preparation  is  to  be  stained,  flood  the  cover-glass,  held  in  forceps,  with  as  much 
of  the  filtered  mordant  as  possible  ;  heat  carefully  above  the  flame  until  the  steam  begins  to 
rise — for  about  a  minute  ;  wash  well  in  distilled  water  until  every  trace  of  the  mordant 
appears  to  be  gone.  If  necessary,  wash  with  absolute  alcohol  until  only  the  film  itself  ap- 
pears to  be  tinted  violet  by  the  mordant ;  filter  a  few  drops  of  the  stain  on  to  the  cover-glass  ; 
again  heat  until  the  steam  rises,  and  leave  in  the  warm  stain  for  one  minute  ;  wash  well  in 
distilled  water;  dry,  and  mount  in  xylol  balsam. 

See  J.  H.  Wright's  staining  method  for  blood. — Jour.  Med.  Res  arch,  Jan.,  1902. 

Procedure  in  Bacteriological  Examinations. — In  surgical 
bacteriology,  as  in  any  other,  a  definite  routine  is  the  best  to  adopt  in 
the  examination  not  only  of  the  materials  submitted,  but  at  the  time 
of  operation. 

In  the  case  of  materials  submitted  for  examination,  there  must  be 
always  (1)  a  microscopic  examination  ;  (2)  an  effort  to  isolate  the  bac- 
teria presented;  and  (3)  an  attempt  at  an  identification. 

Materials  must  be  protected,  so  far  as  possible,  from  contamination 
by  extraneous  bacteria,  and  nothing  must  be  done  that  will  kill  the 
bacteria  that  may  be  contained  in  the  material.  Of  course,  there  is  in- 
cluded the  necessity  for  obtaining  the  material  as  soon  as  possible  after 


SURGICAL   BACTERIOLOGY.  2g 

its  removal  from  its  natural  surroundings.  If  the  material  to  be  ex- 
amined be  fluid,  and  it  is  necessary  to  transfer  it  for  any  distance,  it 
may  be  received  in  sterile  pipets,  which  may  be  drawn  into  capillary 
ends  and  sealed  in  the  flame,  or  which  may  be  plugged  with  cotton  in 
one  end,  whilst  the  other  passes  through  the  cotton  stopper  of  a  sterile 
test-tube.  If  the  fluids  or  tissue-juices  are  to  be  examined  at  once,  this 
may  be  done  by  transferring  a  small  portion,  by  means  of  sterile  plat- 
inum wires,  or  pledgets  of  cotton  wound  upon  the  roughened  ends 
of  ordinary  wire,  to  the  nutrient  medium  that  is  to  be  used  and  the 
cover-glass  that  is  to  be  examined  microscopically.  Tissues  should  be 
obtained,  if  possible,  with  the  organ  to  which  they  belong,  whole. 
These  organs  may  be  examined  by  searing  the  surface  with  a  red-hot 
knife  or  cautery,  making  an  incision  through  this  seared  surface  with 
a  fresh  knife,  and  from  these  freshly  exposed  surfaces  making  cover- 
glass  preparations  and  plate-cultures  ;  or  the  surfaces  may  be  sterilized 
by  thoroughly  soaking  in  I  :  iooo  corrosive-sublimate  solution,  drying 
and  making  an  incision  with  a  sterile  knife,  which  incision  may  be 
deepened  by  tearing,  thus  obtaining  a  perfectly  uncontaminated  surface. 

The  routine  procedure  for  the  bacteriological  examination  of  mate- 
rial in  the  case  of  a  discharge  is  first  to  make  a  number  of  cover-glass 
preparations,  which  may  be  stained  by  Gram's  method  and  with  sev- 
eral other  ordinary  stains  ;  next,  plate-cultures  should  be  made  in 
nutrient  gelatin,  in  nutrient  agar,  and  on  blood-serum,  and  the  develop- 
ment should  be  carefully  studied. 

A  shorter  method  of  making  plate-cultures  is  to  pass  the  needle, 
dipped  in  the  material,  in  three  successive  parallel  lines  over  the  surface 
of  the  blood-serum  or  nutrient  agar,  and  keep  these  cultures  at  blood 
temperature.  This  method,  however,  is  not  as  perfect  as  those  first 
spoken  of. 

As  soon  as  the  colonies  appear  upon  the  plate-culture,  they  should 
be  examined  with  a  low-power  lens.  In  the  case  of  those  that  cannot 
be  identified  by  this  examination,  further  study  must  be  carried  on. 
The  student  should  note  first  the  microscopic  appearance,  including  the 
form,  size,  arrangement,  and  the  staining  reactions  ;  whether  the  organ- 
ism is  motile ;  whether  it  produces  spores  ;  then  the  characteristics  of 
its  growth — how  it  appears  in  its  development  upon  gelatin,  in  needle- 
culture  ;  the  rate  and  form  of  growth  ;  the  presence  or  absence  of 
liquefaction  ;  whether  or  not  it  produces  gas  or  odor ;  whether  or  not 
it  produces  acid ;  and  the  characteristics  of  the  colonies  upon  plate- 
culture  ;  so  also  the  characteristics  of  the  growth  upon  agar  at  a  tem- 
perature of  370  C.  in  bouillon,  on  blood-serum,  on  potato,  milk,  litmus 
media,  sugar  media,  and  peptone  solution.  The  rapidity  of  growth 
should  also  be  noted  ;  whether  or  not  the  bacterium  produces  spores 
or  pigment ;  its  staining  reaction  ;  and  the  result  of  inoculation  experi- 
ments in  animals. 

Practically  all  inoculation  experiments  are  performed  by  means  of  a 
hypodermic  syringe,  and  thus  far  no  syringe  has  given  better  satisfac- 
tion than  the  ordinary  "  Koch  "  syringe  (Fig.  10).  Methods  of  inocu- 
lation may  be  either  (i)  by  simple  scarification  of  the  skin  and  a 
rubbing  in  of  the  infectious  material ;  (2)  by  subcutaneous  injection, 
preferably  near  the  root  of  the  tail  or  between  the  shoulders ;    (3)  by 


30 


INTERNATIONAL    TEXT- BO  OK  OE  SURGERY. 


intraperitoneal  injection  ;  (4)  by  intravenous  injection,  for  which  purpose 
the  vein  of  the  car  is  most  commonly  used;  or  (5)  by  injection  into 
special  regions,  such  as  the  anterior  chamber  of  the  eye,  the  tissue  of 
the  lung,  etc.     Autopsies  on  animals,  dead  or   killed  after  inoculation, 


Fiu.   10 Koch's  syringe:    a,  the  usual    form;  6,  modified    form,  with   glass   barrel   of  small 

caliber,  permitting  the  easy  measurement  of  small  doses  (H.  C.  Ernst). 

should  be  made  as  soon  as  possible  after  death.  The  special  methods 
for  carrying  out  these  examinations  may  be  found  in  the  text-books  on 
the  subject. 

Of  the  special  bacteria  likely  to  be  found  in  surgical  work,  the 
most  common  and  most  important  are  those  concerned  more  or  less 
closely  with  suppuration,  of  which  the  most  common  are  the  following: 

Staphylococcus  pyogenes  aureus,  a  micrococcus  of  irregular  size,  of  an  average 
diameter  of  0.9  ft,  arranged  irregularly  in  masses  (Plate  I,  Fig.  1). 

This  bacterium,  which  is  non-motile,  grows  on  gelatin  plates  in  minute  colonies,  appar- 
ent under  a  low  power  of  the  microscope  after  twenty-four  hours,  granulated  on  the  sur- 
face, and  of  a  brownish  color.  The  colonies  gradually  become  visible  to  the  naked  eye  as 
whitish-yellow  points,  which  later  become  more  distinctly  golden  yellow.  Liquefaction  of 
the  gelatin  occurs  around  them,  and  a  funnel-shaped  depression  appears,  at  the  bottom  of 
which  are  the  colonies.  In  needle-cultures  in  gelatin  the  line  of  development  appears 
along  the  needle-track  on  the  day  after  inoculation,  and  on  the  second  or  third  day  the 
beginning  of  liquefaction  may  be  noted  at  the  upper  portion.  The  liquefaction  progresses 
slowly  at  the  lower  portion  of  the  culture,  more  rapidly  at  the  upper  part ;  as  it  increases, 
the  main  portion  of  the  colony  falls  to  the  bottom  as  a  flocculent  deposit  which  takes  on  a 
golden-yellow  color,  whilst  the  liquefied  portion  remains  turbid  ;  finally,  in  from  one  to 
two  weeks,  the  gelatin  becomes  entirely  liquefied  out  to  the  wall  of  the  tube.  On  agar 
(Plate  2,  Fig.  1)  the  colonies  develop  along  the  needle-track  as  an  abundant,  moist,  shining 
growth,  which  is  well  marked  after  twenty-four  hours  at  the  temperature  of  the  body. 
It  later  takes  on  the  golden-yellow  color,  which  may  be  well  marked  at  the  end  of  forty- 
eight  hours.  On  potato  it  grows  well,  producing  an  abundant  layer  that  also  assumes  a 
golden-yellow  color.  In  bouillon  it  produces  a  uniform  cloudiness,  which  later  sinks  to 
the  bottom,  with  a  brownish-yellow  color.  It  coagulates  milk,  produces  an  acid  reaction 
in  the  various  media,  does  not  produce  spores,  although  it  retains  its  vitality  in  old  cultures 
for  a  considerable  length  of  time,  and  requires  rather  a  higher  temperature  for  its  destruc- 
tion than  most  non-spore-bearing  bacteria  (according  to  Lubbert,  needing  a  temperature  of 
8o°  C.  for  half  an  hour).  It  stains  readily  with  any  of  the  anilin  colors,  and  by  Grain's 
method. 

Pathogenic  Properties. — Injections  of  small  amounts  of  pure  culture  are  usually 
not  followed  by  any  results  ;  but  large  amounts,  or  intravenous  or  intra-abdominal  injec- 
tions, are  usually  followed  by  fatal  results  in  rabbits  or  guinea-pigs  in  a  few  days,  with 
minute  abscess-formation  in  the  kidneys  especially. 

The  Staphylococcus  pyogenes  albus  is  a  micrococcus  less  virulent  than  the  pre- 


Fig.  i. — Staphylococcus  pyogenes  aureus ;  pure  culture  on  blood-serum  after  twenty- 
four  hours  at  22°  C. ;  fuchsin ;   camera  lucida,  oc.  4,  oil  immersion  Tl,z  (Zeiss). 

Fig.  2. — Streptococcus  pyogenes ;  bouillon  culture,  twenty-four  hours;  Lbfner's  methy- 
lene blue  ;  camera  lucida,  oc.  4,  oil  immersion  Jj  (Zeiss). 

Fig.  3. — Bacillus  coli  communis;  agar  culture,  twenty-four  hours  old,  at  220  C. ;  camera 
lucida,  oc.  4,  oil  immersion  fa  (Zeiss). 

Fig.  4. — Glanders  bacillus;  culture  on  potato,  forty-eight  hours  old,  at  37. 6°  C. ;  fuchsin; 
camera  lucida,  oc.  4,  oil  immersion  fa  (Zeiss). 

Fig.  5— Tetanus  bacillus ;  old  culture  on  bouillon,  showing  battledore  forms  and  free 
spores;  camera  lucida,  oc.  4,  oil  immersion  fa  (Zeiss). 

Fig.  6. — Bacillus  of  bubonic  plague  ;  agar  culture,  twenty  four  hours  old  ;  fuchsin  ;  camera 
lucida,  oc.  4,  oil  immersion  fa  (Zeiss). 


Plate  i, 


«t~a  v. 


R     ....  :/    '^-r-' 


-;s. 


t; 

^ 

w' 

« 

v6 — i<~2 

V     * 

*s 

*» 

*ve 

'"; WW* 

s . 

■n 

' 

*• 

.»" 

••  **?.  *.. 

1 

»•■ 

»' 

«•"*». 

'•*■- 

..v             «p 

*•"• 

/ 

\ 

•nt*  ? 

«** 

• 

;'_ 

i   V 

Fig.   i.  Fig.  2. 


-    .     "  f*  0,"  '  '  A 

t  '  -  ' 1  •  —  /      Vf 

'     ,«.     :•'    /\    ',.'*  if,  A,       '      • 


;V 

v         '   v* 

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N\ 

M 

l/»N 

y . 

/J         * 

/  / 


Fig.  3  Fig.  4. 


f    "*  * 


^ 


v. 


n 


/ 


v  \ 


FlG-  5-  Fig.  6. 


SURGICAL   BACTERIOLOGY.  3 1 

ceding,  whose  characteristics  are  precisely  the  same,  with  the  exception  that  its  colonies  are 
white,  and  not  colored. 

The  Staphylococcus  epidermidis  albus  of  Welch  is  probably  but  a  variety  of  the  preced- 
ing, occurring  in  the  deeper  layers  of  the  skin. 

A  third  micrococcus  of  pus,  much  less  common  than  either  of  these  two,  is  the  Staph  = 
ylocoCCUS  pyogenes  citreus,  differing  from  the  others  in  that  its  colonies  are  of  a 
lemon  yellow,  and  the  fact  that  its  pathogenic  properties  are  very  slight. 

The  Staphylococcus  cereus  albus  and  the  Staphylococcus  cereus  flavus  are 
of  practically  no  importance.  They  are  found  occasionally  in  suppurative  processes.  They 
do  not  liquefy  gelatin  ;  the  one  produces  a  white  waxy  growth  upon  ordinary  media,  whilst 
the  other  produces  a  yellow  waxy  growth.  They  have  not  been  shown  to  have  any  special 
pathogenic  properties. 

The  Streptococcus  pyogenes  (Plate  I,  Fig.  2)  is  a  coccus  of  a  somewhat  larger 
average  size  than  the  staphylococcus,  being  about  1  //  in  diameter,  occurring  in  chains  which 
may  be  made  up  of  a  large  or  a  small  number  of  the  cells.  .Sometimes  there  is  the  appear- 
ance of  a  chain  of  diplococci,  because  the  division  of  many  individual  members  of  the  chain 
may  be  going  on  at  the  same  time.  In  young  cultures  the  micrococci  are  uniform  in  size  ; 
but  as  they  grow  older  a  marked  difference  appears,  some  of  the  individuals  being  twice 
the  normal  diameter  and  more.  This  streptococcus  is  non-motile.  On  cultivation  in  gela- 
tin a  very  thin  line  appears  along  the  needle-track,  which  is  seen  to  be  made  up  of  a  row 
of  minute  round  colonics,  whitish  in  color,  rarely  reaching  the  size  of  a  pin's  head.  There 
is  no  growth  on  the  surface  of  the  gelatin,  and  no  liquefaction  or  color-production.  In 
gelatin  plates  the  colonies  also  appear  as  minute  whitish  globular  points,  flat  and  translucent 
upon  the  surface.  On  the  surface  of  agar  the  growth  takes  place  along  the  needle-track  as 
minute  rounded  colonies,  showing  a  marked  tendency  to  remain  separate.  The  character- 
istics upon  blood-serum  are  the  same  as  upon  agar  ;  on  potato  there  is  generally  no  visible 
growth  ;  in  bouillon  there  is  apparent  a  very  fine  cloudiness,  which  later  settles  to  the  bottom 
of  the  tube.  It  coagulates  milk,  and  is  said  occasionally  t<>  produce  gas  in  sugar  media  and 
to  turn  litmus  red.  It  grows  best  at  the  temperature  of  the  body,  and  with  a  fair  degree  of 
rapidity.  It  does  not  produce  spores,  does  not  liquefy  gelatin,  and  produces  no  pigment. 
It  stains  with  any  of  the  anilin  colors  and  by  Gram's  method.  Inoculated  into  the  car  of 
a  rabbit,  it  produces  a  localized  erysipelatous  process  ;  but  usually  subcutaneous  injections 
in  rabbits  and  guinea-pigs  are  without  result. 

It  must  be  remembered  that  one  of  two  things  must  be  true :  either 
there  are  many  kinds  of  streptococci  which  our  present  means  of  study 
do  not  enable  us  to  differentiate,  or  this  streptococcus  takes  on  many 
variations  of  virulence  under  the  influence  of  varying  surroundings. 

Varieties  of  Streptococci. — It  may  be  stated  that  formerly  the  Streptococcus  pyog- 
enes and  the  Streptococcus  erysipelatis  were  regarded  as  two  distinct  species,  and  various 
points  of  difference  between  them  were  given.  Further  study,  and  especiallv  the  results 
obtained  by  modifying  the  virulence,  have  shown  that  these  distinctions  cannot  be  main- 
tained, and  now  nearly  all  authorities  are  agreed  that  the  two  organisms  are  one  and  the 
same,  erysipelas  being  produced  when  the  Streptococcus  pyogenes  of  a  certain  standard  of 
virulence  gains  entrance  to  the  lymphatics  of  the  skin.  Petruschky  in  1896  showed  conclu- 
sively that  a  streptococcus  cultivated  from  pus  may  cause  erysipelas  in  the  human  subject. 

There  is  occasionally  found,  in  the  study  of  surgical  lesions,  a  bacterium  that  produces 
a  striking  greenish-blue  fluorescence  in  the  nutrient  media  on  which  it  grows.  This  is  the 
Bacillus  pyocyaneus,  which  is  of  interest  not  because  it  produces  any  marked  pathological 
changes,  but  by  reason  of  the  studies  that  have  been  made  upon  the  pigment  which  it  pro- 
duces, and  its  apparently  augmenting  effect  when  inoculated  at  the  same  time  with  certain 
other  micro-organisms.  It  is  one  of  a  number,  and  the  characteristics  of  the  group  are  best 
studied  in  the  large  text-books. 

The  Micrococcus  tetragenus  is  also  an  organism  which  very  rarely  occurs  in  sur- 
gical lesions,  characterized  especially  by  the  fact  that  it  divides  in  two  planes  at  right  angles 
to  one  another,  so  that  it  is  frequently  found  in  the  tissues  after  inoculation  in  groups  of 
four,  sometimes  surrounded  by  a  capsule.  The  cocci  stain  easily  with  all  the  ordinary  stains, 
as  well  as  by  Gram's  method.  This  micrococcus  is  about  1  u  in  diameter.  It  grows  readily 
in  gelatin  plates,  as  round  yellowish-white  colonies,  which  appear  granular  or  slightly  nodu- 
lated under  a  low  power.  The  surface  colonies  show  the  yellowish-white  color  more 
markedly.  The  needle-culture  in  nutrient  gelatin  gives  a  fairly  thick  whitish  line  along  the 
track  of  the  needle,  with  a  round,  thick,  yellowish-white  disk  on  the  surface.  The  organism 
grows  abundantly  on  the  surface  of  agar  and  of  potato,  in  a  moist  layer  of  a  yellowish- 
white  color.  It  grows  rapidly  at  the  temperature  of  the  room,  does  not  produce  spores,  and 
does  not  liquefy  gelatin.      It  is  especially  pathogenic  to  white  mice,  a  subcutaneous  injection 


32  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

producing  a  general  septicemia,  the  organisms  being  found  in  large  numbers  in  the  blood 
and  tissues,  especially  the  spleen.  This  micrococcus  has  been  supposed  to  be  active  in  the 
production  of  the  suppurative  part  of  the  destructive  process  in  tuberculosis  of  the  lung. 

Can  suppuration  occur  apart  from  bacteria  ?  This  question  was 
taken  up  after  it  had  been  shown  that  bacteria  were  the  chief  causes 
of  suppuration,  and  efforts  were  made  to  determine  whether  an  actual 
suppuration  could  be  determined  by  simple  chemical  substances,  such 
as  croton  oil,  nitrate  of  silver,  mercury,  and  so  on.  The  general  con- 
clusion reached  seems  to  be  that  suppuration  does  not  usually  follow 
the  introduction  of  these  irritant  substances  ;  but  occasionally  with  some 
of  them,  and  in  certain  animals,  a  suppuration  may  occur,  the  pus  from 
which  does  not  show  bacteria.  This  suppuration  never  produces  sec- 
ondary abscess  of  itself,  nor  upon  inoculation  of  the  pus,  and  it  is  even 
doubted  whether  the  pus  thus  produced  actually  corresponds  histologi- 
cally and  chemically  with  the  results  of  natural  suppuration  ;  in  any 
case,  as  far  as  the  practical  side  is  concerned,  it  is  unquestionable  that 
by  far  the  greater  number  of  cases  of  suppuration  met  with  clinically 
are  produced  by  living  bacteria. 

The  Bacillus  coli  communis  (Plate  I,  Fig.  3)  is  found  in  many  inflammatory  and 
suppurative  conditions  in  connection  with  the  alimentary  tract ;  also  in  other  parts  of  the 
body,  in  inflammation  of  the  urinary  passages,  cystitis,  etc.  It  is  a  bacillus  from  2  to  3  ji 
long  and  about  0.5  fJ-  broad,  with  rounded  ends.  It  is  actively  motile,  and  grows  in  gelatin 
plates  as  small  brownish-white  colonies,  not  liquefying  the  gelatin.  In  nutrient  gelatin  the 
'growth  is  well  marked  along  the  needle-track,  as  a  whitish  line,  spreading  out  upon  the 
surface  of  the  gelatin,  not  much  elevated  from  the  surface  of  the  media  ;  on  agar  it  grows 
distinctly  out  from  the  needle-track,  as  a  whitish-brown  layer,  moist,  dirty  in  appearance  ; 
the  same  appearances  characterize  the  growth  on  blood-serum  ;  on  potato,  in  forty-eight 
hours,  there  is  a  distinctly  brown  pellicle  with  a  dull  surface. 

The  growth  clouds  bouillon,  produces  gas  in  glucose  media,  turns  litmus  media  red,  and 
has  a  marked  indol  reaction  in  peptone  solutions.  It  grows  rapidly — best  at  the  temperature 
of  the  body — does  not  produce  spores,  does  not  liquefy  gelatin,  produces  gas  ( Plate  2,  Fig.  2 ) , 
and  stains  with  any  of  the  anilin  colors,  but  not  by  Gram's  method.  In^-avenous  injection 
of  small  amounts  in  guinea-pigs  will  produce  death,  but  much  larger  amounts  are  required 
to  produce  the  same  results  in  rabbits  or  guinea-pigs  after  intra-abdominal  injection. 

Muir  and  Ritchie  give  the  following  table  of  differences  between  the  Bacillus  typhosus 
and  the  Bacillus  coli  communis  : 

B.    TYPHOSUS.  B.    COLI    COMMUNIS. 

Flagella  more  numerous,   longer  and  more       Flagella  fewer  and  shorter. 

wavy. 
In  artificial  media  the  growth   is   generally       Growth  faster  and  more  vigorous. 

slow  and  not  vigorous. 
Growth  on  fresh  acid  potatoes  a  nearly  trans-       Giowth  on  potatoes  a  brown  pellicle. 

parent  film. 
Very  slight  acid-production  in  ordinary  me-       Well-marked  acid  production. 

dia,  followed  sometimes  by  the  production 

of  alkali. 
Fermentation  of  lactose  very  slight,  if  any.         Fermentation  pronounced. 
Milk  not  coagulated.  Milk  coagulated. 

In  gelatin  "  shake "  cultures   no   gas-forma-       Abundant    gas-formation.      Rounded    colo- 

tion.  nies. 

No  production  of  indol  in  ordinary  bouillon.       Well-marked  indol  production. 
Agglutination.       Bacilli     become     clumped       Bacilli  remain  actively  motile  in  most  cases  ; 

together  and  motionless  in  the  serum  of  a  sometimes  clumping  occurs. 

typhoid    patient.      (A   similar    reaction    is 

given    by  the    blood-serum  of   an  animal 

immunized  against  the  typhoid  bacillus. ) 

Of  the  bacteria  already  mentioned,  the  staphylococci  are  most 
commonly  found  in  localized  abscesses  or  pustules,  carbuncles,  boils, 


Plate  2. 


c. 


Fig.  I. — Staphylococcus  pyogenes  aureus;  pure  culture  on  blood-serum,  four  days  old, 
at  37. 6°  C. ;  natural  size. 

Fig.  2. — Bacillus  coli  communis ;  pure  culture  on  glucose-gelatin  after  forty-eight 
hours  at  22°  C,  showing  gas-production  ;  natural  size. 

Fig.  3. — Bacillus  tuberculosis;  pure  culture  on  glycerin-agar,  three  weeks  old;  natural 
size. 


SURGICAL   BACTERIOLOGY.  33 

in  acute  suppurative  periostitis,  in  ulcerated  endocarditis,  and  in  cer- 
tain pyemic  conditions.  The  streptococci  are  usually  found  in  spread- 
ing inflammations,  with  or  without  suppuration,  in  diffuse  phlegmonous 
and  erysipelatous  conditions,  in  suppurations  in  certain  membranes, 
and  in  joints.  The  Bacillus  coli  communis  is  found  in  many  inflam- 
matory and  suppurative  conditions  in  connection  with  the  alimentary 
tract  and  elsewhere.  The  Micrococcus  tetragenus  is  found  especially 
in  suppurations  in  the  region  of  the  mouth  or  neck,  as  well  as  in 
various  lesions  of  the  respiratory  tract.  The  Bacillus  pyocyaneus  is 
rarely  found  alone  in  pus. 

The  gOIlOCOCCUS  is  a  constant  accompaniment  of  that  specific  form  of  suppuration 
known  as  gonorrhea.  Its  special  characteristic  is  that  it  is  a  micrococcus  occurring  most 
commonly  in  pairs,  with  the  adjacent  edges  flattened  or  even  slightly  concave.  Another  of 
its  marked  characteristics  is  that  it  most  commonly  occurs  in  the  leukocytes,  which  is  differ- 
ent from  what  is  the  case  in  ordinary  suppuration.  It  stains  easily  and  well  with  any  of  the 
ordinary  dyes,  but  does  not  stain  by  Gram's  method. 

Neisser's  stain  gives  very  beautiful  results  (Plate  3,  Fig.  I).  Cover-glasses  in  warm 
concentrated  alcoholic  eosin,  two  to  three  minutes.  Transfer  directly,  after  soaking  off 
excess  with  filter-paper,  to  concentrated  alcoholic  methylene-blue,  one-half  to  three-quarters 
of  a  minute.  Wash  in  water,  dry,  and  mount.  (These  times  of  staining  have  been  found 
to  be  better  than  those  originally  given. ) 

The  cultivation  of  the  gonococcus  is  difficult.  It  does  not  grow  upon  the  ordinary 
media.  The  best  are  solidified  blood-serum  and  Wertheim's  medium,  consisting  of  I  part 
of  fluid  serum  and  2  parts  of  agar  at  a  temperature  of  400  C,  which  is  then  allowed 
to  solidify  by  cooling.  Growth  occurs  best  at  the  temperature  of  the  body,  and  does  not  go 
on  below  250  C.  The  cultures  are  to  be  obtained  by  passing  a  small  quantity  of  pus  over  the 
surface  of  one  of  the  selected  media,  and  then  placing  it  in  an  incubator.  The  colonies 
make  their  appearance  at  the  end  of  twenty-four  hours  as  small  translucent  bodies,  irregu- 
larly rounded,  and  reach  their  maximum  size  on  the  fourth  or  fifth  day.  The  later  cultures 
grow  more  luxuriantly  than  do  the  earlier  ones,  but  the  transference  to  fresh  media  must  be 
made  every  two  or  three  days.  Aside  from  the  occurrence  of  the  gonococcus  in  fresh  pus, 
its  relation  to  joint-affections  and  other  sequelae  is  a  matter  of  considerable  importance. 
There  is  no  question  that  in  a  certain  number  of  cases  of  gonorrheal  arthritis  and  in  inflam- 
mations of  the  sheaths  of  tendons  the  gonococcus  has  been  found  microscopically,  and  pure 
cultures  have  been  made  ;  and  also  that  in  a  large  number  of  such  cases  no  bacteria  have 
been  identified. 

Certain  peculiarities  of  the  fluid  in  the  joints  in  which  the  gono- 
coccus has  been  found  have  been  mentioned,  such  as  a  whitish-yellow 
tint,  turbid  appearance,  shreds  of  fibrin-like  material,  sometimes  almost 
purulent  in  its  appearance ;  it  has  also  been  occasionally  shown  that 
the  gonococci  are  more  numerous  on  the  surface  of  the  membrane 
lining  the  synovial  cavity  than  in  the  fluid. 

For  diagnostic  purposes  the  appearance  of  the  gonococci  in  pairs, 
their  characteristic  arrangement  within  the  cell-protoplasm  in  fresh 
pus,  staining  easily  with  the  ordinary  colors  and  not  staining  by  Gram, 
furnish  the  group  of  microscopic  appearances.  For  the  determination 
by  cultivation  Wertheim's  medium,  or  blood-agar,  should  be  used,  or 
Wright's  urine-serum-agar,  as  described  below. 

Urine-serum-agar  (Mallory  and  Wright,  p.  144)  is  useful,  as  demonstrated  by  Wright, 
for  the  cultivation  of  the  gonococcus.  To  a  quantity  of  melted  agar-agar  at  400  C.  is 
added  a  mixture  of  I  part  urine  and  2  parts  beef  blood-serum  equal  to  y^  to  y^  the  volume 
of  the  agar-agar.  The  mixture  of  urine  and  serum  is  freed  from  bacteria  by  passing  through 
a  Chamberland  filter.  The  mixture  is  allowed  to  solidify  in  test-tubes,  and  must  be  tested 
for  contamination  in  the  incubator. 

Soft  Chancre. — For  some  years  little  attention  was  paid  to  this  lesion,  because  there 
was  a  widespread  opinion  that  it  was  a  filth-disease  ;  but  later  observations,  notably  those  of 
Ducrey  and  Unna,  have  shown  the  constant  presence  of  a  bacillus  in  this  form  of  ulceration, 
and  no  other,  although  it  has  not  been  possible  to  cultivate  it  upon  artificial  media.      It  is  a 

3 


34  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

small  oval  rod,  about  1. 5  11  in  length  and  0.5  //  in  breadth,  and  occurs  in  the  discharge  from 
the  surface,  or,  in  sections,  more  deeply  situated  than  other  bacteria,  in  bunches  and  in 
chains  that  may  be  stained  in  cover-glass  preparations.  Great  care  must  be  taken  not  to 
decolorize  too  strongly,  for  the  bacillus  itself  is  easily  decolorized. 

Syphilis. — The  bacillus  of  Lustgarten,  described  about  fourteen  years  ago,  is  the  only 
one  thai  has  ever  been  ascribed  to  this  disease  with  any  appearance  of  probability;  and 
while  it  resembles  in  certain  respects  both  the  bacillus  of  tuberculosis  and  the  smegma 
bai  i  1 1  us.  it  may  be  differentiated  limn  either  of  them  by  a  special  method. 

Lustgarten's  staining  of  the  tissues  to  demonstrate  the  bacilli  was  as  follows:  Place  the 
sections  for  from  twenty-four  to  forty-eight  hours  in  anilin-water  gentian  violet ;  then  wash 
in  alcohol,  and  place  for  ten  seconds  in  a  1  l/z  per  cent,  solution  of  potassium  permanganate  ; 
decolorize  with  sulphurous  acid  (25  per  cent,  solution)  to  remove  the  brown  precipitate  as 
well  as  to  decolorize  the  tissues  ;  wash  in  water  ;   dehydrate  and  mount. 

Like  the  bacillus  of  soft  chancre,  this  syphilis  bacillus  has  not  been  successfully  cultivated. 
Hueppe's  method  of  differentiating  between  the  syphilis,  smegma,  leprosv,  and  tubercu- 
losis bacilli  is  :  I.  Treat  the  preparation,  stained  with  carbol-fuchsin,  with  sulphuric  acid  ; 
the  syphilis  bacillus  becomes  decolorized  almost  instantaneously.  2.  If  not  at  once  decol- 
orized, treat  with  alcohol  ;  this  will  remove  the  color  from  the  smegma  bacillus.  3.  If  still 
not  decolorized,  it  is  either  the  bacillus  of  tuberculosis  or  that  of  lerjrosy.  (Adapted  from 
Abbott' s  Bacteriology. ) 

Diplococcus  Pneumoniae  (Frankel's  pneumococcus  ;  Microbe  of  Sputum  septicemia  ; 
Micrococcus  Pasteuri  ;  Diplococcus  lanceolatus) . — Under  these  headings  may  be  placed  a 
description  of  the  diplococcus  that,  while  not  usually  producing  primary  surgical  results, 
may  often  occur  associated  with  the  pyogenic  cocci.  It  is  of  grave  importance  in  medicine. 
It  occurs  not  infrequently  in  the  saliva  of  healthy  persons,  with  great  abundance  in  the 
expectoration  of  certain  forms  of  pneumonia,  and  has  been  studied  associated  with  the 
septic  cocci. 

The  best  method  for  securing  a  pure  culture  is  by  subcutaneous  inoculation  of  material 
containing  it  (Plate  3,  Fig.  2)  in  rabbits  or  guinea-pigs;  in  which  case  the  animals  die  in 
from  twenty-four  to  forty-eight  hours,  and  the  blood  and  tissues  are  found  to  be  filled 
with  this  micro-organism.  It  is  an  oval  coccus,  occurring  usually  in  pairs,  and  may  be 
surrounded  by  a  capsule.  The  colonies  are  not  apparent  upon  ordinary  gelatin  plates 
or  in  gelatin  tubes,  for  the  reason  that  the  bacterium  does  not  grow  below  22°  C.,  so 
that  cultures  are  best  seen  after  development  upon  agar  at  the  temperature  of  the  blood. 
In  this  case  the  colonies  appear  as  minute,  almost  transparent  drops,  looking  almost  like 
small  drops  of  water.  They  grow  best  upon  blood-serum,  as  an  almost  transparent  line 
along  the  needle-track,  with  isolated  colonies  at  the  edges,  later  becoming  more  or  less 
confluent.  The  colonies  on  agar  plates  are  almost  invisible,  but  may  be  seen  by  means  of 
a  low-power  lens,  and  appear  to  have  a  compact,  finely  granulated  center,  with  almost 
translucent  edges.  There  is  a  slight  cloudiness  produced  in  bouillon,  which  later  settles  to 
the  bottom  of  the  test-tube.  There  is  no  visible  growth  upon  potato.  It  is  very-  difficult  to 
keep  the  cultures  alive,  and  to  do  so  they  must  be  renewed  every  three  or  four  days,  and 
even  then  are  fairly  certain  to  die  out  in  the  course  of  two  or  three  months.  It  is  impossible 
to  retain  the  virulence  of  the  micro-organism  under  cultivation.  This  must  be  done  by  the 
passage  through  animals.  Its  growth  is  slow  except  at  the  temperature  of  the  body.  It 
does  not  produce  spores,  does  not  liquefy  gelatin,  does  not  produce  gas,  is  facultatively- 
anaerobic,  stains  with  the  ordinary  dyes  and  by  Gram's  method,  and  produces  septicemia 
upon  subcutaneous  inoculation. 

Tuberculosis. — The  bacillus  of  tuberculosis  occurs  in  all  lesions  of  the  disease.  It 
is  a  small  rod,  on  the  average  from  2.5  to  3.5  ft  in  length  and  0.3  u  in  breadth.  It  occurs 
singly  or  in  pairs,  arranged  either  end  to  end  or  like  the  arms  of  the  letter  V.  It  is  non- 
motile.  The  unstained  portions  of  the  rod  have  been  by  some  supposed  to  be  spores,  but 
this  is  not  generally  accepted.  It  does  not  grow  upon  ordinary  gelatin  or  upon  ordinary 
nutrient  agar.  It  does,  however,  develop  upon  both  of  these  media  if  from  6  to  8  per  cent, 
of  glycerin  have  been  added  to  them  (Plate  2,  Fig.  3).  Its  best  growth,  however,  is  found 
upon  blood-serum  at  the  temperature  of  the  body.  On  this  medium  its  colonies  present  a 
characteristic  appearance.  They  are  seen  first  as  small  brownish-yellow  dots,  and  never 
before  the  eighth  or  ninth  dav.  They  increase  in  size,  coalesce,  and  form  a  heavy,  wrinkled, 
dirty-brown  or  cream-colored  layer  extending  outward  three  or  four  lines  on  each  side  of 
the  needle-track,  and  in  undisturbed  cultures  grow  upon  the  surface  of  the  water  of  con- 
densation, leaving  the  fluid  below  perfectly  clear.  Once  seen,  these  colonies  are  almost 
unmistakable  for  anything  else.  The  growth  upon  potato,  which  is  sometimes  seen,  but 
not  always,  present-  similar  characteristics.  The  bacillus  is  of  slow  growth,  develops  only 
at  the  temperature  of  the  body,  does  not  liquefy  gelatin,  probably  does  not  produce  spores, 
produces  no  gas  or  odor,  stains  with  difficulty  with  the  ordinary  anilin  colors,  decolorizes 
with  equal  difficulty,  and  produces  tuberculosis  upon  inoculation  in  all  susceptible  animals. 
The  difficulties  in  cultivating  the  bacillus  of  tuberculosis  would  present  an  almost  insuper- 


SURGICAL   BACTERIOLOGY.  35 

able  obstacle  to  the  diagnosis  of  tuberculous  processes  by  this  method.  Fortunately,  how- 
ever, Ehrlich  showed  that  this  bacillus  has  a  special  staining  reaction  by  which  it  may  be 
differentiated  from  any  others  with  which  it  is  likely  to  be  confounded.  Taking  advantage 
of  the  resistance  of  this  bacterium  to  the  decolorizing  action  of  the  mineral  acids,  Koch  and 
Ehrlich  worked  out  a  differential  stain,  than  which  no  better  method  has  ever  been  suggested 
for  the  detection  of  small  numbers  of  the  bacilli  in  suspected  material.  For  cover-glasses 
this  method  is  as  follows  : 

I.  Cover-glasses  prepared  in  the  usual  way  are  stained  over  night — better  for  twenty-four 
hours — in  anilin- water  fuchsin  (or  gentian  violet).  2.  Transfer  at  the  end  of  that  time  to 
nitric  acid  (1:4)  for  a  few  seconds.  3.  Place  in  60  per  cent,  alcohol  for  one  minute  to 
complete  decolorizing.  4.  Wash  in  water.  5.  Stain  in  watery  methylene  blue  (or  vesuvin, 
if  gentian  violet  was  the  first  stain  used)  for  one  to  two  minutes;  wash  thoroughly;  dry 
carefully;  mount  in  oil  of  cedar  or  Canada  balsam   (Plate  3,  Fig.  3). 

Sections  are  stained  in  precisely  the  same  way,  with  the  exception  that  in  place  of  the 
nitric  acid,  I  part  to  4,  a  little  stronger  bath  of  nitric  acid  is  used,  I  part  to  3,  because,  the 
sections  being  thicker  than  the  film  on  the  cover-glass,  a  somewhat  stronger  decolorizing 
agent  is  necessary*.  Of  course,  after  the  washing  following  the  use  of  the  methylene  blue, 
the  sections  are  to  be  dehydrated,  cleared  in  oil  of  cedar,  and  mounted  in  Canada  balsam 
(Plate  3,  Fig.  4). 

The  efficiency  of  this  stain  lies  in  the  fact  that  the  nitric  acid  appears  to  exert  some 
direct  coagulant  (  ?  )  action  upon  the  capsule  of  the  bacillus  itself.  This  action  is  practically 
instantaneous,  and  results  in  placing  the  capsule  in  such  a  condition  that  it  resists  the  further 
decolorizing  action  of  the  nitric  acid,  so  that  the  bacillus  remains  stained.  This  is  not  true 
with  other  bacilli  ;  all  other  bacteria  are  completely  decolorized,  except  the  bacillus  of 
leprosy  and  the  smegma  bacillus  ;  aj"id  if  the  source  of  the  material  allows  any  possibilitv 
of  confusion  with  these  two,  the  method  of  differentiation  already  given  will  serve  to  put  an 
end  to  any  doubt. 

The  method  as  given  by  Koch  suggests  the  use  of  gentian  violet  as  the  first  stain  (  with 
fuchsin  as  the  second  choice)  and  vesuvin  as  the  contrast  stain  (with  methylene  blue  as 
the  second  choice),  the  result  of  which  would  be,  of  course,  a  blue-stained  body  upon  a 
brown  ground  ;  whilst  the  method  preferred  here,  gives  red-stained  rods  upon  a  blue 
ground.  This  is  the  result  that  has  been  found  by  far  the  most  useful,  for  it  is  much  more 
easy  for  the  eye  of  the  average  student  to  detect  a  minute  red  body  upon  a  blue  ground 
than  it  is  to  find  a  minute  blue  body  upon  a  brown  ground.  Much  objection  is  constantly 
raised  to  this  method  of  staining  because  of  the  time  that  must  elapse  before  the  material  is 
ready  for  the  microscope,  and  innumerable  short  ready  methods  have  been  suggested,  not 
one  of  which  is  as  reliable  as  this,  but   many  of  which  are  much  more  used. 

The  most  common  of  these  is  the  so-called  Ziehl's  method.  In  this  method,  as  in  the 
others,  advantage  is  taken  of  the  resistance  of  the  bacillus  of  tuberculosis  to  decolorizing 
agents.  As  in  the  first  method  given  the  anilin  oil  is  used  as  a  mordant  to  intensify  the 
action  of  the  first  stain,  so  in  this  method  the  aid  of  a  still  stronger  mordant  is  sought  and 
found  in  carbolic  acid.  The  first  procedure  in  the  Ziehl-Nielsen  method,  which  is  applicable 
only  to  cover-glasses,  is  as  follows  :  Cover-glasses  prepared  after  the  usual  method  are 
stained  in  carbol  fuchsin  for  thirty  minutes  ( this  time  may  be  shortened  to  ten  minutes  by 
warming  the  staining  fluid);  decolorize  in  sulphuric  acid  (1  part  to  4)  for  a  few  seconds; 
wash  in  water  ;  a  contrast  stain  is  obtained  by  watery  methylene  blue  for  two  or  three  min- 
utes ;  the  cover-glasses  are  then  thoroughly  washed  in  water,  carefully  dried,  and  mounted. 
In  this  method,  as  there  is  a  stronger  mordant  used  in  the  carbolic  acid,  so  there  is  a  stronger 
decolorant  used  in  sulphuric  acid.  Experience  has  demonstrated  that  while  this  stain  may 
be  useful  for  showing  the  presence  of  large  numbers  of  bacilli,  it  cannot  be  relied  upon 
when  there  are  but  few.  Of  this  method,  as  of  all  the  short  methods  yet  presented,  it  may 
be  said  that  if  one  finds  rods  stained  red  on  a  blue  ground,  the  presence  of  the  bacilli  may 
be  acknowledged  ;  yet  if  such  rods  are  not  found,  the  absence  of  the  bacilli  cannot  with 
safety  be  asserted. 

Gabbet's  method  of  staining  is  one  frequently  used,  combining  the  decolorizing  and  the 
second  stain.  1.  Stain  cover-glasses  with  carbol -fuchsin,  hot,  for  one  minute.  2.  Wash  in 
water.  3.  One  half  minute  in  Gabbet's  methylene  blue  (Methylene  blue  2,  sulphuric  acid 
25,  water  75).     4.    Wash  thoroughly,  dry,  and  mount. 

In  examining  suspected  material  for  purposes  of  diagnosis  in  tuberculosis,  cover-glass 
preparations  are  to  be  made  in  quite  large  numbers,  and  thoroughly  studied  after  being 
stained  by  one  or  more  of  the  methods  suggested  ;  but  inoculation  experiments  are  sometimes 
successful  when  the  microscopic  examination  fails,  so  that  recourse  should  be  had  to  these 
inoculation  experiments  if  the  matter  of  diagnosis  is  one  of  importance  and  the  microscopic 
examination  has  failed  to  demonstrate  the  bacilli.  Inoculation  experiments  are  more  com- 
monly necessary  in  the  diagnosis  of  surgical  tuberculosis  than  in  other  forms  of  the  disease. 
The  bacillus  being  more  often  present  in  the  granulations  and  lining  membranes  of  abscess- 
cavities,  it  is  to  be  looked  for  especially  in  these  tissues  rather  than  in  the  contained  fluid. 


36 


INTERNATIONAL    Til XI- BOOK  OF  SURGERY. 


Glanders. — Glanders  occurs  not  infrequently  in  human  beings  by  direct  infection  from 
diseased  animals.  Occasionally  il  is  a  mailer  of  importance  to  be  able  to  make  a  differential 
diagnosis  between  this  disease;,  as  manifested  in  the  human  subject,  and  certain  oilier  condi- 
tions. There  is  a  specific  bacillus  connected  with  the  disease,  discovered  by  Loffler  and 
Schutz,  the  announcement  being  made  in  1882.  The  bacillus  which  is  found  in  the  tissues 
affected  has  been  subjected  to  observation  under  artificial  conditions,  and  the  disease  has 
been  reproduced  upon  inoculation.  The  bacillus  is  a  small  rod,  from  1-2  //  in  length, 
either  straight  or  slightly  curved,  and  with  round  ends  (Plate  I,  Fig.  4).  Portions  of  the 
protoplasm  not  infrequently  refuse  to  take  the  stains,  and  somewhat  resemble  spores. 
The  glanders  bacillus  is  non-motile.  Satisfactory  study  of  the  colonies  in  gelatin  cannot  be 
obtained,  for  the  reason  that  the  glanders  bacillus  does  not  develop,  excepting  very  slightly, 
below  25°C.  (  )n  agar  the  culture  appears  along  the  needle-track  as  a  grayish-white,  slightly 
transparent  layer,  moist  and  slimy,  which  later  becomes  of  a  brownish  color.  On  blood- 
serum  the  growth  is  somewhat  similar  but  more  translucent,  separate  colonies  occurring  in 
the  form  of  round,  almost  clear  drops,  blood  serum  is  by  far  the  best  medium  for  its  devel- 
opment. In  bouillon  there  is  at  first  a  uniform  cloudiness,  which  later  settles  to  the  bottom, 
forming  a  thick,  flocculent  deposit.  On  potato  the  glanders  bacillus  grows  very  well  at 
blood  temperature,  forming  a  marked,  elevated,  translucent  yellowish  growth,  almost  like 
clear  honey  ;  later  the  growth  becomes  darker  and  more  opaque,  until  at  about  the  end  of  a 
week  it  takes  on  a  reddish  brown  or  chocolate  color,  while  the  potato  at  the  margin  of  the 
colony  often  shows  a  greenish-yellow  stain.  This  growth  is  characteristic  of  the  glanders 
bacillus,  taken  in  connection  with  the  microscopic  appearance.  The  development  of  the 
bacillus  is  rapid  at  blood  temperature.  It  probably  does  not  produce  spores,  for,  although 
it  is  not  killed  at  once  by  drying,  it  loses  its  vitality  in  about  two  weeks  in  a  dry  state.  The 
cultures  retain  their  vitality  for  from  two  to  four  months  if  removed  from  the  incubator  after 
growth  has  occurred,  but  they  die  quickly — in  from  three  to  four  weeks — when  kept  con- 
stantly at  the  body-temperature.  They  have  but  slight  powers  of  resistance  to  heat  and 
antiseptics  ;  all  of  which  tends  to  show  that  they  do  not  produce  spores.  The  bacillus  does 
not  liquefy  gelatin,  nor  does  it  produce  gas  ;  it  produces  the  yellowish  honey-like  color.  It 
stains  with  the  ordinary  watery  solutions  but  faintly,  and  decolorizes  very  readily  indeed,  so 
that  a  fairly  strong  stain  should  be  used  in  the  first  place,  and  very  mild  measures  of  decol- 
orization  should  afterward  be  employed.  The  alkaline  methylene  blue  of  Loffler  for  five 
minutes;  then  decolorize  for  a  few  seconds  in  a  mixture  of  water  10  c.c,  10  drops  of  a 
strong  solution  of  sulphurous  acid,  and  I  drop  of  a  5  per  cent,  solution  of  oxalic  acid  (as 
recommended  by  Loffler).  Muir  and  Ritchie  obtained  the  best  results  with  carbol-Thionin- 
blue,1  dehydrating  by  the  anilin-oil  method.  In  using,  dilute  I  part  with  3  parts  of  water, 
and  filter.  Stain  sections  for  five  minutes  or  upward.  Wash  very  thoroughly  in  water,  to 
prevent  later  deposit  of  crystals.  Decolorize  with  very  weak  acetic  acid  (a  few  drops  to  a 
glassful  of  water).  Wash  thoroughly  in  water.  Dehydrate,  and  clear  with  anilin  oil,  then 
with  anilin  oil  and  xylol  equal  parts,  then  with  xylol.  This  bacillus  does  not  stain  by  Gram's 
method. 

The  diagnosis  of  glanders  may  be  readily  made  by  taking  advantage  of  the  peculiar 
affinity  that  the  glanders  bacillus  has  for  the  testicular  tissue  of  the  guinea-pig.  If  a  small 
portion  of  the  suspected  material  be  injected  subcutaneously  over  the  abdomen  of  a  male 
guinea-pig,  the  testicles  will  become  much  enlarged  in  from  twenty-four  hours  to  three  days 
if  the  glanders  bacilli  be  present.  Microscopic  examination  of  tissue-scrapings  will  show 
the  presence  of  the  bacilli  in  large  numbers. 

Leprosy. — Leprosy,  so  far  as  surgical  bacteriology  is  concerned,  need  be  spoken  of 
only  to  say  that  in  the  lesions  there  always  occur,  especially  in  the  tubercular  form,  large 
numbers  of  bacilli  that  microscopically  and  in  staining  reaction  resemble  very  closely  the 
bacillus  of  tuberculosis.  They  are  present  for  the  most  part  within  the  protoplasm  of  the 
round-cell-  infiltration,  and  are  frequently  arranged  in  bundles  lying  side  by  side  ;  occa- 
sionally one  or  two  are  found  on  the  surface  epithelium,  although  for  the  most  part  they 
are  confined  to  the  leukocytes  and  the  connective-tissue  elements.  They  have  not  been 
satisfactorily  cultivated  outside  of  the  body.  For  microscopic  observation  cover-glass  prep- 
arations may  be  made  from  any  ulcerations  found,  or  from  scrapings  from  a  portion  of 
excised  tissue.  They  may  be  stained  by  Gram's  method,  or  by  carbol-fuchsin,  using,  for 
decolorizing,  a  weaker  solution  of  sulphuric  acid  than  in  the  case  of  the  bacillus  of  tubercu- 
losis, for  the  reason  that  the  bacillus  of  leprosy  is  decolorized  more  easily  than  is  the  bacillus 
of  tuberculosis.  A  contrast-stain  may  be  obtained  with  the  watery  solution  of  methylene 
blue. 

Actinomycosis. — The  fungus  producing  this  disease  is  not  a  true  bacterium,  but  it  is 
of  great  interest,  because  certain  cases  of  surgical  disturbance  are  produced  by  it ;  and  by 
observation  of  the  actinomycosis  fungus  a  differential  diagnosis  from  tuberculosis  or  other 

1  Carbol-Thionin-Blue. — Stock  solution  of  I  gm.  Thionin-blue  in  100  c.c.  carbolic-acid 
solution,  I  :  40. 


Fig.  i. — Gonococcus  in  pus,  stained  by  Neisser's  method;  camera  lucida,  oc.  4.  oil 
immersion   ^5  (Zeiss). 

Fig.  2. — Croupous  pneumonia  sputum,  showing  Frankel's  diplococcus  and  capsules ; 
Ziehl's  carbol-fuchsin ;  camera  lucida,  oc.  4,  oil  immersion  Tx2  (Zeiss). 

Fig.  3. — Bacillus  tuberculosis  in  sputum;  Koch-Ehrlich  stain;  camera  lucida,  oc.  4,  oil 
immersion  -^2  (Zeiss). 

Fig.  4. — Bacillus  tuberculosis  in  human  gland;  Koch-Ehrlich  stain;  camera  lucida,  oc. 
4,  oil  immersion  T!2  (Zeiss). 

Fig.  5. — Bacillus  actinomyces  in  human  gland;  stained  by  Gram's  method;  camera 
lucida,  oc.  4,  obj.  5  (Zeiss). 

Fig.  6. — Anthrax  bacilli  in  the  heart's  blood  of  a  mouse;  fuchsin;  camera  lucida,  oc.  4, 
oil  immersion  Tx2  (Zeiss). 


Plate  3. 


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SURGICAL    BACTERIOLOGY.  37 

processes  may  not  infrequently  be  made.  In  the  tissues  the  fungus  forms  little  round  masses, 
the  largest  being  of  the  size  of  a  small  pin's  head,  lying  free  in  the  pus,  if  the  breaking 
down  of  the  tissues  has  gone  so  far  as  suppuration,  or  embedded  in  the  granular  tissue. 
They  may  be  of  various  colors,  usually  described  as  yellow,  but  this  is  not  the  most  common 
appearance.  They  are  more  frequently  white,  greenish,  or  almost  black,  whilst  they  may 
be  also  transparent  or  jelly-like.  Under  the  microscope  there  occur:  I.  Filaments,  on  the 
average,  0.5  ft  in  diameter,  and  often  of  considerable  length  (Plate  3,  Fig.  5).  In  the  center 
of  the  colony  these  filaments  are  frequently  interlaced,  and  at  the  edges  often  spread  out  in  a 
more  or  less  symmetrically  radiating  manner.  The  name  "ray  fungus"  has  been  given 
because  of  this  appearance.  2.  Cocci  or  conidia,  which  are  spherical  bodies  formed  from 
the  filaments,  probably  by  transverse  subdivision.  3.  Club-shaped  bodies  found  at  the 
periphery  of  the  colonies,   and  really  the  filaments  with   swollen  sheaths. 

These  organisms  do  not  stain  by  Gram's  method,  but  take  the  contrast-stain.  They  do 
not  always  occur  in  affected  human  tissues,,  but  may  be  found  very  frequently,  practically 
always,  in  the  ox,  and  in  the  tissues  from  this  animal  they  retain  the  gentian  violet  in  Gram's 
stain. 

The  origin  of  this  parasite  is  probably  on  grain,  especially  on  barley.  The  obtaining 
of  pure  cultures  is  extremely  difficult,  and  while  growth  occurs  at  the  ordinary  temperature 
of  the  room,  it  is  verv  slow.  Portions  of  the  tissue  should  be  broken  up  on  the  surface  of 
glycerin-agar  and  placed  at  the  temperature  of  the  body.  If  there  are  no  other  bacteria 
present,  in  three  or  four  days  the  colonies  will  appear  in  the  form  of  small  transparent  drops, 
graduallv  enlarging,  forming  rounded  elevations  of  a  reddish-yellow  color.  The  colonies 
are  dull,  adhere  to  the  surface  of  the  agar,  and  sometimes  have  a  wrinkled  surface  and  an 
appearance  as  if  .they  had  been  covered  with  a  brownish-yellow  powder.  The  parasite 
grows  well  also  in  the  anaerobic  condition  on  agar.  Unopened  eggs,  either  fresh  or  boiled, 
have  also  been  used,  the  inoculation  being  made  through  a  small  hole  drilled  in  the  shell, 
which  is  afterward  closed.  On  gelatin  whole  spherical  colonies  appear,  and  there  occurs 
very  slow  liquefaction,  the  liquefied  portion  being  brownish  and  thick,  with  the  colonies  at 
the  bottom  as  little  balls.      The  growth  upon  potato  is  very  similar  to  that  upon  agar. 

Anthrax  |  Woolsorterf  disease;  Malignant  pustule  :  Splenic  fever). — This  process,  with 
its  bacillus,  is  of  great  interest  because  it  is  one  of  the  first  in  which  the  bacteria  were  con- 
nected with  disease  ;  by  reason  of  the  fact  that  the  action  of  germicides  is  tested  upon 
anthrax  spores  ;  and  because  it  was  one  of  the  first  affections  in  which  immunity  by  the  use 
of  attenuated  cultures  was  sought  to  be  obtained. 

The  bacilli  occur  in  the  blood  and  tissues  of  man  or  animals  attacked  by  anthrax 
(Plate  3,  Fig.  6).  They  are  from  6  to  8  ft  long  and  about  1.2  ft  broad,  with  square  or  slightly 
concave  ends.  They  sometimes  occur  in  long  chains,  frequently  in  pairs  arranged  end  to  end. 
They  stain  well  with  all  the  basic  anilin  colors,  and  by  Gram's  method,  although  a  cautious 
application  of  the  decolorizing  fluid  is  necessary  in  order  to  avoid  removing  the  gentian 
violet  from  many  of  the  bacilli.  On  gelatin  plates  the  colonies  develop,  in  from  twenty-four 
to  thirty-six  hours,  as  verv  wavy  bodies,  radiating  from  the  center  outward  like  locks  of  hair. 
In  a  day  or  two  a  liquefaction  begins  which  slowly  extends  through  to  the  bottom  of  the 
gelatin.  In  gelatin  tubes  an  appearance  is  seen  similar  to  that  of  the  colonies  in  gelatin 
plates,  the  growth  appearing  along  the  needle-track  as  a  whitish  line  sending  out  radiating 
lines  and  presenting  the  appearance  of  an  inverted  fir-tree,  whitish,  and  accompanied  by 
liquefaction  slowly  progressing  downward  from  the  upper  portion  of  the  gelatin.  In  agar 
plates  the  colonies  are  apparent  twelve  hours  after  incubation  at  a  temperature  of  37 °  C, 
under  a  low  power,  presenting  this  very  marked  wavy  appearance.  Under  a  high  power 
the  wavy  appearance  apparently  radiates  out,  and  terminates  not  in  a  point,  but  in  a  turn 
upon  itself;  so  that  it  is  probable  that  the  entire  colony  is  a  thread  twisted  on  itself.  On 
the  surface  of  agar  there  is  a  moist,  profuse  growth,  slightly  elevated,  ami  whitish  in  color, 
showing  the  wreathed  appearance  that  is  seen  in  plate-cultures.  The  colonies  on  blood- 
serum  are  the  same  as  on  agar.  In  bouillon  there  appears  a  shreddy  growth  that  later 
becomes  more  abundant,  settling  as  a  flocculent  mass  to  the  bottom  of  the  fluid.  On  potato 
there  is  a  thick,  moist,  whitish  layer,  without  any  special  characteristics.  The  bacillus 
grows  rapidly,  producing  spores,  does  not  produce  gas,  liquefies  gelatin  slowly,  does  not 
produce  pigment,  is  stained  readily  with  any  of  the  anilin  colors,  and  usually  by  Gram's 
method,  and  is  pathogenic  to  all  susceptible  animals. 

For  diagnostic  purposes  cover-glass  preparations  may  be  made  from  the  fluid  in  the 
vesicles,  or  from  scrapings  of  the  incised  pustule,  and  may  be  stained  with  watery  solutions 
of  any  of  the  anilin  colors,  and  by  Gram's  method.  The  bacilli  are  not  usually  found  in 
the  blood.  Muir  and  Ritchie  give  a  very  wise  caution  that  the  parts  should  be  handled 
carefully  and  gently  in  attempts  at  diagnosis,  otherwise  the  diffusion  of  the  bacilli  into  sur- 
rounding tissues  may  be  forced,  and  the  condition  greatly  aggravated.  Plate-cultures  should 
also  be  made,  as  well  as  inoculations,  if  positive  results  are  not  obtained  by  the  microscope 
alone. 

Tetanus. — The  etiology  of  tetanus  was  slow  in  development,  from  a  bacteriological 


38 


INTERNATIONAL    TEXTBOOK   OF  SURGERY. 


point  of  view,  for  the  reason,  demonstrated  after  a  long  series  of  investigal  ions,  that  the  bacil- 
lus of  tetanus  does  not  grow  in  cultures  from  tissues  excepting  under  anaerobic  conditions. 

I  bis  bacillus  was  first  described  by  Nicolaier  in  1885,  but  Kitasato  was  the  first  to  suc- 
ceed in  cultivating  it  separate  from  other  bacteria.  The  bacillus  itself  is  from  4  to  5  //  long 
and  0.5//  broad,  with  somewhat  rounded  ends  (Plate  I,  Fig.  5),  and  without  any  special 
characteristics  except  when  it  is  in  the  spore-producing  stage.  In  this  case  the  spore  occurs 
at  one  end  of  the  rod,  is  round,  and  has  a  diameter  three  or  four  times  the  thickness  of  the 
rod.  In  specimens  stained  with  a  watery  solution  of  gentian  violet  or  methylene  blue  the 
spores  are  unstained  excepting  at  the  edges,  so  that  the  appearance  of  a  small  ring  is  pro- 
duced.  The  rods  occur  singly  or  in  threads.  The  bacilli  are  motile,  and  when  stained  to 
demonstrate  the  cilia,  these  are  seen  to  occur  either  singly,  or  at  both  ends,  or  all  about  the 
rod. 

Inasmuch  as  the  bacillus  does  not  usually  grow  excepting  under  anaerobic  conditions, 
ordinary  plate-cultures  are  not  commonly  attempted  for  obtaining  the  pure  cultures  from  any 
discharge  in  which  the  spore-bearing  tetanus  bacilli  have  been  seen.  Muir  and  Ritchie 
suggest  the  following  method  : 

Inoculations  with  the  suspected  material  are  made  in  half  a  dozen  deep  tubes  of  glucose- 
agar,  previously  melted  and  kept  at  a  temperature  of  ioo°  C.  After  inoculation  these  tubes 
are  again  placed  in  boiling  water,  and  kept  for  varying  times — from  half  a  minute,  to  one, 
two,  three,  four,  five,  or  six  minutes  ;  they  are  then  plunged  in  cold  water  until  cold,  and  are 
afterward  placed  in  an  incubator  at  370  C,  in  the  hope  that  in  one  or  the  other  of  the 
tubes  all  the  organisms  present  will  have  been  killed  except  the  tetanus  spores,  which  can 
then  develop  in  pure  culture.  The  isolation  of  the  tetanus  bacilli  is  in  many  cases  a  difficult 
matter,  and  various  expedients  must  be  tried.  If  the  attempt  at  securing  pure  cultures  be 
successful,  further  cultures  can  be  made  in  deep  upright  tubes  of  glucose-gelatin  or  agar. 
In  agar  the  growth  is  not  characteristic,  the  colonies  appearing  as  small  nodules  along  the 
needle-track,  with  very  slight  formation  of  gas ;  in  glucose-gelatin  the  growth  occurs  an 
inch  or  two  below  the  surface,  and  consists  of  fine,  straight  threads,  rather  longer  in  the 
lower  than  in  the  upper  part  of  the  tube,  radiating  out  from  the  needle-track,  together  with 
slight  liquefaction  and  slight  gas-formation.  Growth  also  occurs  in  blood-serum  and  glu- 
cose-bouillon under  anaerobic  conditions.  By  far  the  best  development  is  at  a  temperature 
of  370  C,  and  only  in  the  absence  of  oxygen,  the  bacillus  being  anaerobic.  Spores  are 
produced  at  the  end  of  twenty-four  hours  in  cultures  grown  at  370  C,  much  later  at  lower 
temperatures.  The  bacillus  produces  gas  in  sugar  media,  may  be  stained  easily  by  any  of 
the  anilin  dyes  and  by  Gram's  method,  and  is  pathogenic  to  the  lower  animals,  reproducing 
the  disease  upon  inoculation  in  small  quantities.  There  is  very  little  to  be  found  micro- 
scopically, except  localized  punctate  hemorrhages  in  the  spinal  canal  ;  not  much  change 
occurs  in  the  other  organs  of  the  body. 

Attempts  have  been  made  to  determine  the  nature  of  the  tetanus  toxin — for  with  this 
disease,  as  with  diphtheria,  the  main  symptoms  are  the  result  of  the  action  of  toxin  produced 
during  the  growth  of  the  bacillus — and  very  extensive  experiments  have  been  conducted  in 
the  direction  of  securing  an  antitetanus  serum. 

The  experiments  in  the  production  of  immunity  against  tetanus  in  animals  have  been 
successful  ;  but  the  use  of  the  serum  of  immunized  horses  in  cases  of  human  tetanus  has  not 
been  equally  so,  probably  because  the  symptoms  of  tetanus  do  not  appear  sufficiently  marked 
until  the  progress  of  the  disease  has  passed  beyond  the  stage  at  which  curative  treatment  is 
likely  to  be  successful. 

For  the  bacteriologic  examination  of  a  suspected  case,  there  should  be,  first,  the  micro- 
scopic examination  of  the  secretion  from  the  wound,  which  may  easily  fail  unless  the  drum- 
stick forms  are  found  ;  cultures  in  deep  tubes  of  glucose-agar  or  glucose-gelatin  should  be 
made,  kept  at  the  temperature  of  the  body  for  twenty-four  hours,  and  then  examined,  when 
the  spore-bearing  bacilli  may  be  detected  ;  finally,  inoculation  experiments  should  be  tried 
upon  mice  or  guinea-pigs. 

Occasionally  it  seems  to  be  true,  as  demonstrated  by  Theobald  Smith,  that  the  tetanus 
bacillus  will  grow  in  mixed  cultures  not  under  the  ordinary  anaerobic  conditions.  In  such 
cases  a  possible  explanation  is  that  the  oxygen  in  the  nutrient  medium  is  used  up  by  the 
other  bacteria.  Advantage  has  been  taken  of  this  peculiarity  by  R.  M.  Pearce,  now  of  the 
University  of  Pennsylvania,  who  has  succeeded  in  isolating  the  tetanus  bacillus  from  a 
mixed  culture  in  which  it  had  developed. 

Malignant  Edema. — This  disease  occurs  in  human  beings  as  a  spreading  inflamma- 
tory edema,  accompanied  by  emphysema,  and  later  followed  by  gangrene  of  the  skin  and 
adjacent  parts.  The  disease  is  produced  by  the  bacillus  of  malignant  edema,  first  described 
by  Pasteur  as  the  "  vibrion  septique."  Like  the  bacillus  of  tetanus,  this  bacillus  is  present 
not  uncommonly  in  garden-soil,  manure,  and  various  putrefying  fluids.  It  is  rather  a  large 
bacillus,  occurring  in  rods  from  3  to  10  fi  long,  not  infrequently  growing  out  into  long  fila- 
ments, but  on  solid  media  generally  occurring  as  short  rods  with  somewhat  rounded  ends. 
It  is  motile,  with  flagella  placed  on  the  sides.     It  forms  spores,  which  are  present  usually 


SURGICAL    BACTERIOLOGY.  39 

at  about  the  center  of  the  rod.  As  this  bacillus  develops  only  under  anaerobic  conditions, 
it  may  be  differentiated  by  this  fact  alone  from  the  anthrax  bacillus,  which  it  somewhat 
resembles  under  the  microscope. 

In  gelatin  plates,  under  anaerobic  conditions,  the  colonies  appear  as  small  whitish 
points,  which  under  a  low  power  show  radiating  appearances  soon  masked  by  a  zone  of 
liquefaction.  In  deep  tubes  of  glucose-gelatin  the  growth  appears  as  a  whitish  line,  giving 
off  minute  short  processes,  never  reaching  within  an  inch  of  the  top  of  the  medium,  with 
the  occurrence  of  liquefaction  and  the  settling  of  the  colonies  to  the  bottom.  In  deep  tubes 
of  glucose-agar  at  a  temperature  of  37°  C.  the  growth  i>  very  rapid,  as  a  broad  white  line 
along  the  line  of  puncture,  with  lateral  projections  here  and  there,  and  a  very  profuse  pro- 
duction of  gas.  The  cultures  have  a  peculiar  heavy  odor  that  is  quite  characteristic.  The 
growth  is  rapid  ;  it  produces  spores  that  are  well  seen  within  forty-eight  hours  at  37°  C.  ;  it 
produces  gas,  liquefies  gelatin,  and  stains  ea>ily  with  any  of  the  anilin  colors,  but  not  by 
Gram's  method  ;  upon  subcutaneous  inoculation  in  any  susceptible  animal  it  produces  the 
characteristic  svmptoms  of  widespread  edema,  gas-production,  and  gangrene. 

For  purposes  of  diagnosis,  the  microscope  is  not  particularly  useful,  for,  microscopically 
the  bacillus,  unless  in  the  stage  of  spore-production,  does  not  possess  characteristics  sufficient 
to  identify  it.  Cultures  may  be  made  in  glucose-gelatin  as  roll-cultures,  and  kept  under 
anaerobic  conditions.  If  the  bacilli  contain  spores,  the  fluid  may  be  kept  at  a  temperature 
of  8oG  C.  for  ten  minutes,  and  then  a  deep  glucose-agar  tube  should  be  inoculated  and  kept 
at  the  temperature  of  the  body.  An  inoculation  experiment  with  the  suspected  material  may 
also  be  tried  in  guinea-pigs. 

Bubonic  Plague.  —  Whilst  bubonic  plague  does  not  occur  endemically  in  America, 
there  is  more  or  less  constant  danger  of  its  transmission  from  Hong  Kong  or  India  to  the 
Pacific  Coast  ;  and  the  fear  of  an  epidemic  was  aroused  recently,  so  that  a  description  of  the 
bacillus  described  independently  by  Kitasato  and  by  Yersin  may  not  be  out  of  place. 

The  bacillus  is  found  in  the  glands  affected  by  this  disease  as  small  oval  rods  with  rounded 
ends.  Many  of  the  bacilli  stain  at  the  ends  only,  leaving  an  unstained  portion  in  the  center. 
They  usually  occur  singly,  but  not  infrequently  are  found  in  pairs  ;  and  in  cultures,  especially 
in  fluid  media,  they  have  a  tendency  to  grow  into  chains  1  Plate  1,  Fig.  6).  They  are  non- 
motile,  appearing  in  gelatin  plates  as  small  spherical,  whitish  colonies,  without  liquefaction. 
In  gelatin  tubes  the  colonies  grow  along  the  needle-track  as  isolated  globular,  whitish 
bodies,  with  a  thin,  semi-transparent  layer  on  the  surface.  On  agar  the  growth  is  along  the 
line  of  the  needle-track,  whitish,  smooth,  shiny,  somewhat  transparent  in  appearance,  and 
made  up  of  isolated  colonies  growing  together.  The  same  appearance  is  seen  upon  blood- 
serum.  In  bouillon  the  growth  collects  especially  along  the  foot  and  sides  of  the  tube. 
The  bacillus  grows  rapidly  at  the  temperature  of  the  body,  or  as  low  as  l8°  C.  It  does  not 
produce  spores  ;  it  does  not  produce  gas  ;  it  does  not  liquefy  gelatin  ;  it  stains  easily  with 
any  of  the  anilin  colors,  but  does  not  stain  by  Gram's  method. 

All  the  smaller  animals  usually  used  for  experiment  are  readily  susceptible  to  the  inocu- 
lation. They  become  affected  with  an  inflammatory  swelling  of  the  lymphatic  glands,  and 
especially  by  a  profuse  diarrhea.  It  has  been  noted  that  during  an  epidemic  of  bubonic 
plague  an  especially  high  rate  of  mortality  has  occurred  among  rats  and  mice  in  the  infected 
district,  and  it  is  thought  that  such  a  mortality  is  not  infrequently  the  beginning  of  an  epi- 
demic among  human  beings.      Flies  also  are  responsible  for  the  spread  of  the  disease. 

Yersin  appears  to  have  been  successful  in  his  attempts  to  secure  an  anti-plague  serum, 
and  the  reports  are  now  sufficiently  detailed  to  permit  a  proper  appreciation  of  their  great 
importance. 

Rhinoscleroma. — Rhinoscleroma  is  rare  in  America  and  in  England,  but  is  not  un- 
common in  some  parts  of  the  continent  of  Europe.  It  is  characterized  by  chronic  nodular 
thickenings  of  the  skin  or  the  mucous  membrane  of  the  nose,  pharynx,  larynx,  or  trachea. 
In  the  tissues  of  these  nodules  bacilli  have  been  found — short  oval  rods  surrounded  by  a 
distinct  capsule. 

In  its  microscopic  and  cultural  appearances  the  bacillus  of  rhinoscleroma  resembles  very 
closely  that  of  Friedlander  ;  and  while  slight  differences  have  been  made  out,  it  is  undoubt- 
edly a  member  of  the  same  group.  These  differences,  as  summarized  by  Baumgarten,  are 
that  this  bacillus  always  has  a  capsule,  in  cultures  as  well  as  in  the  ti>sues  ;  that  it  is  more 
decidedly  rod-shaped  than  the  bacillus  of  Friedlander  ;  and  that  it  stains  by  Gram's  method, 
whilst  Friedlander' s  bacillus  does  not.  The  bacillus  of  rhinoscleroma  is  a  short  bacillus 
with  rounded  ends,  occurring  singly  and  in  pairs,  and  surrounded  by  a  distinct  capsule.  It 
is  non-motile.  On  gelatin  plates  the  colonies  appear  as  yellowish-white  granular  bodies  in 
two  or  three  days.  In  gelatin  tubes  the  growth  appears  along  the  needle-track  as  a  whitish 
granular  line,  and  as  an  almost  hemispherical  elevation  on  the  surface,  giving  the  appear- 
ance, in  profile,  of  a  round-headed  nail  driven  into  the  gelatin.  Upon  the  surface  of  agar 
the  growth  is  profuse  along  and  on  both  sides  of  the  needle-track,  as  a  dirty-white  moist 
layer  ;  on  potato  a  profuse  cream-white  growth  occurs  along  the  surface.  The  best  growth 
is  at  a  temperature  of  37°  C.      The  growth  is  fairly  rapid.      The  bacillus  is   non-spore-bear- 


40  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

ing,   non-liquefying,   and  aerobic.     It  stains  easilv  with  any  of  the  anilin   colors,  and  by 
Gram's  method,  and  is  pathogenic  for  mice  and  guinea-pigs,  but  less  so  for  rabbits. 

The  Bacillus  aerogenes  capsulatus,  as  described  by  Welch  and  Flexner,1  is 
an  interesting  bacterium  that  may  be  found  at  autopsies,  and  which  has  been  shown  to 
possess  pathogenic  properties  in  man.  It  is  a  rod  from  3  to  6  ,»  in  length  and  0.5  to  1  //  in 
breadth,  with  rounded  or  square  ends,  occurring  singly,  in  pairs,  and  occasionally  in  chains 
or  threads.  Being  strictly  anaerobic,  cultures  must  be  made  under  these  conditions.  <  olo 
nies  are  gray  or  brownish-white,  with  a  central  darker  spot  by  transmitted  iight,  increasing 
to  2  to  3  mm.  in  size.  Deep  colonies  may  be  oval  or  spherical,  with  feathery  projections. 
The  bacillus  is  non-pathogenic,  but  the  tissues  of  animals  1  rabbits)  killed  immediately  after 
the  intravenous  injection  of  a  suspension  of  bouillon,  and  kept  for  a  few  hours  at  a  tempera- 
ture of  300  to  50°  C,  contain  a  large  amount  of  gas  and  many  bacilli. 

DEVELOPMENT  OF   SERUM-THERAPEUTICS. 

The  advance  in  our  knowledge  of  bacteria  has  led  to  great  increase 
of  activity  in  attempts  to  prevent  the  appearance  of  the  symptoms 
of  an  infectious  disease  after  exposure  to  its  virus,  or  the  arrest  and 
cure  of  these  symptoms  after  they  have  made  their  appearance.  Such 
attempts  have,  of  course,  been  made  from  the  time  when  medicine 
began,  but  have  met  with  the  smallest  amount  of  success  so  far  as  the 
use  of  drugs,  as  this  term  is  commonly  employed,  is  concerned.  The 
first  efforts  with  a  knowledge  of  the  bacteria  and  their  action  as  a  basis 
were  those  in  which  the  attempt  was  made  to  secure  the  attenuation 
of  the  virus  of  the  disease,  and  the  use  of  this  modified  virus  against 
an  attack  of  the  disease  itself.  The  idea  underlying  this  is  the  substi- 
tution of  a  disease  of  a  milder  type  for  that  of  the  full  strength,  the 
attack  of  the  milder  form  being  supposed  to  protect  the  system  against 
the  more  virulent.  Such  attempts  have  been  carried  on  with  at  least 
partial  success  in  such  diseases  as  anthrax  and  rabies.  They  represent 
the  direction  in  which  the  earliest  efforts  of  Pasteur  and  his  followers 
were  made.  These  investigators  have  not  thus  far,  however,  seemed 
to  define  any  general  principle  upon  which  further  work  may  be  based, 
nor  do  their  results  seem  to  serve  as  a  foundation  for  reasoning,  ex- 
cept in  the  individual  disease  that  the  experiments  cover. 

Tuberculin  is  the  result  of  efforts  along  a  different  line,  and 
illustrates  the  attempt  to  establish  a  different  principle.  It  con- 
sists essentially  of  the  nutrient  material  in  which  the  bacteria  have 
grown,  freed  of  the  bacteria  by  filtration,  but  containing  all  the  com- 
pounds that  have  resulted  from  their  growth.  The  use  of  this  material 
(tuberculin)  is  an  example  of  the  second  method,  by  means  of  which 
it  has  been  sought  to  secure  curative  effects  in  infectious  disease  ;  that 
is,  by  the  application  of  the  products  of  bacterial  growth,  as  obtained 
in  the  test-tube,  to  the  destruction  of  the  organisms  that  produced 
them,  or  at  least  to  the  arrest  of  the  development  of  these  organisms. 

The  third  and  apparently  the  most  successful  method  for  combat- 
ing the  infectious  diseases,  from  the  therapeutic  point  of  view,  is  the 
employment  of  certain  properties  that  may  be  naturally  present  or 
artificially  produced  in  the  blood-serum  of  various  animals. 

It  is  a  long  time  since  the  theory  that  immunity  might  be  due  to 
some  deterrent  element  in  the  blood  was  suggested — this  substance 
being  something  that  would  prevent  the  growth  of  the  invading  bac- 
teria or  neutralize  their  toxic  products — and  it  has  been  an  exceedingly 
1  Jour,  of  Exp.   Med.,  Vol.  I.,  No.  I.,  1896. 


SURGICAL   BACTERIOLOGY.  4 1 

difficult  matter  to  sift  the  conflicting  evidence  offered.  The  first  ex- 
perimental researches  were  negative  (Grawitz  and  Gamaleia) ;  but  in 
1884,  Grohmann  showed  that  fresh  serum  exerted  an  attenuating  in- 
fluence upon  the  bacilli  of  symptomatic  anthrax ;  Fodor  found  that 
fresh  blood  destroyed  them ;  while  Nuttall  established  the  fact  that 
organic  fluids  (serum,  aqueous  humor,  pericardial  fluid),  really  possessed 
the  power  of  destroying  bacteria,  and  that  this  germicidal  action  was 
taken  away  by  raising  these  fluids  to  a  temperature  of  above  500  C. 
Buchner  found  that  this  power  rested  solely  in  the  serum,  and  that  the 
breaking  up  or  mixing  in  of  the  blood-corpuscles  masked  or  diminished 
its  activity.  Following  Buchner,  the  important  work  was  that  of 
Ogata  and  Iasuhara,  and  Behring  and  Kitasato  in  pointing  out  the 
great  influence  of  the  fluid  portions  of  the  animal  tissues  in  the  pro- 
duction of  immunity.  From  the  work  of  these  authors  it  appears  that 
immunity  is  due  to  the  action  of  albuminoid  substances,  called  by 
Hankin  "defensive  proteids,"  which  have  the  power  of  (1)  destroying 
pathogenic  bacteria,  (2)  of  attenuating  them,  or  (3)  of  neutralizing  the 
effects  of  or  destroying  their  toxic  products. 

First  as  to  the  "  germicidal  proteids."  Certain  animals  have  in  their 
blood  and  the  other  fluids  of  their  body  substances  endowed  with  a 
very  considerable  germicidal  action,  an  example  that  has  been  much 
studied  being  the  blood  of  the  white  rat.  These  animals  are  refrac- 
tory to  inoculation  with  anthrax,  and  the  reason  for  this  immunity  to 
a  disease  so  virulent  has  been  found  (Behring)  to  exist  in  the  fact  that 
the  animal's  blood-serum  destroys  the  bacterium.  By  comparative 
tests  it  was  shown  that  2.5  c.cm.  of  rat's  serum  would  have  the  same 
germicidal  action  as  would  the  same  quantity  of  corrosive  sublimate 
in  the  strength  of  I  :  1000,  or  of  carbolic  acid  1  :  50.  To  appreciate 
this  fact  it  is  necessary  to  consider  another  quality  of  these  chemicals 
— their  toxic  action  upon  the  animals.  It  thus  appears  that  the  sub- 
limate and  carbolic-acid  solutions  will  kill  the  animal  in  a  dose  one- 
fifth  to  one-seventh  of  that  necessary  to  secure  their  germicidal  action, 
and  cannot,  therefore,  be  thought  of  for  internal  antisepsis.  On  the 
other  hand,  the  germicidal  proteids  are  present  in  quantity  sufficient 
for  complete  activity  in  the  serum  of  a  perfectly  healthy  white  rat. 
These  proteids  are,  therefore,  the  least  toxic  of  all  germicides  known. 
Many  points  are  still  to  be  made  out — as,  for  instance,  such  an  appar- 
ent contradiction  as  that  the  germicidal  power  does  not  in  all  cases 
correspond  to  the  natural  immunity  of  the  animal  that  furnishes  the 
serum  ;  but  at  least,  as  the  experimental  knowledge  of  the  subject  has 
increased,  working  hypotheses  have  been  suggested  for  most  of  these 
contradictions. 

The  second  class  of  these  proteids  is  made  up  of  the  "attenuating" 
varieties,  the  existence  of  which  was  first  suggested  by  the  fact  that 
the  bacteria  of  symptomatic  anthrax  were  attenuated  in  virulence  when 
injected  into  animals  refractory  to  the  disease,  whilst  their  vitality  was 
not  interfered  with.  The  experiments  of  Ogata  and  Iasuhara  first 
showed  that  the  attenuating  property  lay  in  the  serum  of  the  animals 
experimented  upon.  The  existence  of  these  attenuating  proteids  has 
been  demonstrated  by  other  observers  in  anthrax  and  other  dis 
eases. 


42  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

The  progress  of  research  has,  however,  shown  that  there  is  a  third 
class  of  proteids,  the  antitoxic  ;  and  their  discovery  is  the  most  impor- 
tant of  all,  not  only  because  the  results  obtained  with  them  are  so 
important,  but  because  it  almost  appears  that  the  germicidal  and 
attenuating  proteids  are  to  be  included  among  the  antitoxic.  The  two 
former  are  supposed  to  act  upon  the  bacteria  themselves ;  the  last, 
upon  their  products.  The  first  announcement  of  results  in  this  direc- 
tion was  made  by  Behring  and  Kitasato  in  1890.  They  had  found 
that  the  blood  of  rabbits  protected  against  tetanus  had  the  power  of 
destroying  the  toxic  alkaloid  of  tetanus  (tetanin)  during  the  lifetime  of 
the  animal  attacked,  and  that  it  was  not  only  possible  to  protect  an 
animal  against  inoculation  of  the  tetanus  bacilli,  but  also  to  cure  it 
after  the  appearance  of  the  symptoms  of  the  disease.  The  application 
of  these  facts  to  human  tetanus  has  not  been  as  successful  as  was  at 
first  hoped  for,  probably  because  it  is  not  usually  possible  to  apply  the 
remedy  sufficiently  early  in  the  disease. 

Almost  in  the  same  week  with  the  announcements  of  Behring  and 
Kitasato  with  reference  to  tetanus  came  those  of  Frankel  and  Brieger 
upon  diphtheria,  which  have  been  followed  by  such  striking  results  in 
the  treatment  of  this  disease  in  man. 

Very  similar  results  have  been  obtained  in  animals  in  the  case  of 
some  of  the  suppurative  bacteria,  the  streptococci,  and  in  anthrax  and 
swine-erysipelas.  The  important  fact  has  also  been  demonstrated  that 
each  disease  is  a  problem  by  itself,  and  that  the  minuter  details  of 
technic  must  be  worked   out  for  each  one. 


CHAPTER    II. 

HYPEREMIA;  INFLAMMATION;  LOCAL  INFECTION  AND 
ITS  TERMINATIONS. 

HYPEREMIA. 

The  old  term  "  congestion  "  was  used  to  denote  a  condition  closely- 
allied  to  inflammation,  but  as  pathology  and  histology  became  more 
accurate  the  condition  known  as  hyperemia  was  sharply  defined  from 
inflammation.  The  term  was  used  to  denote  a  functional  instead  of  an 
organic  disturbance.  Inflammation  was  then  divided  into  simple  and 
septic  inflammations,  the  former  being  caused  by  trauma  in  some  form, 
and  the  latter  by  bacteria.  Since  the  recognition  of  bacteria  as  the 
source  of  a  constantly  enlarging  number  of  inflammatory  processes, 
some  writers  have  inclined  to  the  view  that  all  true  inflammations  are 
septic.  Many  of  those  processes,  known  still  as  inflammations  by 
most  writers,  but  which  could  not  be  placed  under  this  category,  have 
been  assigned  by  some  surgeons  (Park  and  Senn)  back  again  to  the 
domain  of  "  congestion." 

If,  however,  we  adhere  closely  to  pathological  and  physiological 
conditions,  we  find  that  there  is  an  essential  difference  between  the 
hyperemias  and  even  the  simpler  forms  of  inflammation.  In  hyperemia 
we  have  a  more  or  less  transitory  change  of  function,  which  leaves  the 
tissues  essentially  as  they  were  before.  In  inflammation,  on  the  other 
hand,  there  is  a  distinct  organic  change  brought  about  by  an  influence 
which  has  produced  more  profound  disturbance. 

Hyperemia  signifies  an  increased  amount  of  blood  in  a  part,  and  is 
in  contrast  with  ischemia,  which  means  a  decreased  flow  of  blood  to  a 
part.  It  is  of  two  kinds,  active  and  passive.  In  active  hyperemia 
there  is  an  increased  flow  of  arterial  blood.  In  passive  hyperemia 
there  is  a  slowing  of  the  blood-current — a  stagnation — and  the  blood 
is  venous  in  color. 

Active  Hyperemia. — In  this  form  of  hyperemia  there  is  an  in- 
creased rapidity  of  the  flow  of  blood  through  both  the  arteries  and 
veins,  and  the  color  of  the  part  is  a  bright  red ;  there  is  even  an  arterial 
color  in  the  smaller  veins  of  the  part,  and  at  times  they  seem  to  pul- 
sate. Under  the  microscope  it  can  be  seen  that  the  capillaries  are  filled 
with  arterial  blood,  and  they  also  appear  to  be  dilated  (Fig.  n).  Or- 
dinarily there  is  no  edema,  as  the  vessels  hold  the  fluid  and  no  exuda- 
tion takes  place.  It  is  rare  that  there  is  any  extravasation  of  blood  as 
the  result  of  active  hyperemia.  There  is  an  increased  warmth  in  the 
part  affected,  as  more  warm  blood  from  the  interior  of  the  body  flows 
through  it. 

43 


44 


1XTERNATI0NAL    TEXT-BOOK   OF  SURGERY. 


The  vasomotor  nerves  concerned  in  these  functional  changes  are 
the  vasoconstrictors,  the  vasodilators,  and  the  perivascular  ganglia. 

Hyperemia  of  paralysis  is  that  form  of  active  hyperemia  produced 
by  the  paralysis  of  the  vasoconstrictors.  This  condition  may  be  pro- 
duced experimentally  by  division  of  the  splanchnics,  which  produces  a 
dilatation  of  the  mesenteric  and  renal  arteries.  This  congestion  may 
be  so  extensive  as  to  withdraw  blood  from  the  greater  part  of  the  bod)-, 


FlG.  ii. — Normal  circulation  in  vein,  artery, 
and  capillary. 


FIG.  12. — Circulation  in  hyperemia. 


producing  a  condition  similar  to  that  known  in  the  so-called  Goltz  ex- 
periment, which  consists  in  tapping  the  abdomen  of  the  frog  with  light 
but  frequent  blows.  This  causes  a  temporary  cessation  of  respiration, 
heart-pulsation,  and  muscular  action,  from  which  condition,  however, 
the  animal  speedily  recovers. 

Groningen  reports  the  case  of  a  laborer,  lying  on  his  back  after  a  full  meal,  who  was 
playfully  hit  upon  the  stomach  with  a  plank  ;  in  fifteen  minutes  he  was  dead,  and  at  the 
autopsy  no  structural  lesion  could  be  found  in  any  part  of  the  body.  A  more  familiar 
example  of  hyperemia  of  paralysis  is  gunshot  injury  of  the  cervical  sympathetic,  in  which 
flushing  of  that  side  of  the  face  occurs,  and  also  dilatation  of  the  pupil  of  the  same  side, 
with  redness  of  the  conjunctiva,  secretion  of  tears,  and  hyperidrosis.  .Such  a  condition  has 
been  observed,  after  fracture  of  the  clavicle,  from  pressure  on  the  cervical  sympathetic. 

Hyperemia  of  irritation  is  caused  by  irritation  of  the  vasodilator 
nerves.  It  is  shorter  and  quicker  in  its  action,  and  is  accompanied 
often  by  other  active  nervous  symptoms,  such  as  pain.  The  flushing 
accompanying  facial  neuralgia  and  herpes  zoster  is  supposed  to  belong 
to  this  variety.     Reflex  hyperemias  belong  to  this  class. 

Hyperemia  caused  by  paralysis  of  the  perivascular  ganglia  is  that 
form  produced  by  purely  local  causes,  such  as  pressure.  This  is  the 
form  seen  after  removal  of  the  Esmarch  bandage,  or  tapping  the  abdo- 
men for  ascites,  or  suddenly  emptying  an  overdistended  bladder. 


LXFLAMMA  TION. 


45 


Active  hyperemia,  of  whatever  form,  is  a  passing  condition,  and 
when  the  congestion  has  subsided  there  is  no  appreciative  change  in 
the  affected  part.  It  may,  how- 
ever, predispose  to  inflammatory 
changes,  as  the  resisting  power  of 
a  tissue  thus  affected  is  diminished, 
and  a  soil  may  be  made  favorable 
to  bacterial  infection. 

Passive  hyperemia  is  due 
to  partial  or  complete  obstruction 
of  the  flow  of  blood  through  the 
veins.  It  is  purely  mechanical  in 
character.  There  is  cyanosis  of 
the  part  affected,  and  its  tempera- 
ture is  subnormal.  If  the  small 
veins  and  capillaries,  when  in  this 
condition,  are  observed  under  the 
microscope,  they  are  found  to  be 
distended  with  blood-corpuscles 
which  appear  to  be  more  or  less 
fused  together.  The  flow  of  blood 
ceases  at  certain  points,  and  ex- 
travasation of  red  blood-corpuscles 
occurs  (Fig.  13).  There  is  at  the 
same  time  an  escape  from  the  vessels 
giving  rise  to  edema. 


Fig.  13. — Passive  hyperemia. 


of  a  certain  amount  of  fluid. 


A  familiar  example  is  seen  in  the  lower  extremities  in  varicose  veins.  Here  all  the 
stages  of  the  process  can  be  seen.  At  first  there  is  only  edema.  Later  there  is  pigmenta- 
tion of  the  skin,  due  to  the  destruction  of  the  extravasated  red  blood-corpuscles.  The 
impairment  of  the  tissues  thus  brought  about  may  ultimately  lead  to  ulceration.  Hypostatic 
congestion  is  another  form  of  passive  hyperemia,  and  when  it  occurs  in  the  lungs,  as  it  often 
does  in  the  aged  when  confined  to  bed,  it  may  pave  the  way  for  pneumonia.  It  is  due  to 
the  enfeebled  circulation  in  many  forms  of  disease  that  pressure  upon  certain  points  of  the 
body  readily  causes  passive  congestion  and  stasis — thus  giving  rise  to  bed-sores. 


INFLAMMATION. 

Inflammation  may  be  divided  into  two  principal  varieties — simple 
and  infective.  To  the  former  variety  belong  those  produced  by  trauma 
or  injury  (such  as  a  fracture)  and  those  due  to  chemical  action  (such  as 
that  produced  by  drugs,  as  salivation,  or  that  produced  by  ivy-poison- 
ing, or  the  action  of  escharotics).  The  infective  inflammations  are 
those  produced  by  bacteria  or  the  chemical  substances  evolved  by 
them. 

In  simple  inflammation  we  have  a  disturbance  in  the  nutrition  of  a 
part,  brought  about  usually  by  trauma,  which  has  been  best  expressed 
by  the  word  "  damage."  It  may  be  defined  as  a  lesion  in  the  mechan- 
ism of  nutrition,  owing  to  which  its  efficiency  is  impaired,  but  which,  if 
not  so  severe  as  to  cause  death,  is  followed  by  changes  favorable  for 
the  protection  and  repair  of  the  part. 

As  will  be  seen  presently,  there  is,  in  addition  to  the  congestion  of 


46  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

hyperemia,  a  leakage  of  the  vessels  which  gives  rise  to  exudation  and 
other  processes  which  produce  an  organic  change  in  the  part  affected. 

It  was  formerly  supposed  that  these  changes  were  part  of  the  proc- 
ess of  repair,  and  that  a  smart  reaction  was  needed,  after  an  injury,  to 
bring  about  an  active  reparative  process  to  ensure  the  healing  of  a 
wound.  The  changes  produced  by  inflammations  are,  on  the  contrary, 
those  expressive  of  damage  rather  than  repair.  In  the  type  of  inflam- 
mation of  which  we  are  speaking  there  are  no  progressive  changes 
such  as  are  seen  in  the  infective  form,  but  simply  those  resulting  from 
injury.  They  are  fortunately  of  such  a  nature  as  not  to  interfere  with 
the  process  of  repair,  which  in  due  time  makes  itself  manifest. 

The  causes  of  simple  inflammation  are  not  only  trauma,  but  all 
those  which  are  not  bacterial.  In  addition  to  the  chemical  action 
above  referred  to,  the  question  has  been  raised  as  to  the  role  played  by 
the  nerves  in  inflammation. 

The  influence  of  the  nerves  has  long  been  recognized  as  an  agent 
active  in  the  nutrition  of  a  part.  The  theory  of  the  trophic  action  of 
the  nerves  was  based  upon  the  experiments  on  the  vagus  and  tri- 
geminus. 

After  division  of  the  ophthalmic  branch  of  the  fifth  pair  a  necrosis  of  the  cornea  occurs, 
and  the  so-called  vagus-pneumonia  follows  division  of  that  nerve.  These  inflammations 
m  are  now  classed  with  the  infective  inflammations,  as  it  is  known  that,  the  protective  inner- 
vation having  been  withdrawn,  the  tissues  are  exposed  to  bacterial  action.  Still,  clinically, 
we  meet  with  many  types  of  inflammation  so  intimately  associated  with  reflex  action  that  it 
is  difficult  to  assume  that  all  are  due  solely  to  bacteria.  Many  of  the  cases  of  urethral  fever 
which  are  supposed  to  be  typical  examples  of  reflex  inflammation  are  now  well  known  to  be 
due  to  infection  ;  but  a  certain  number  are  difficult  to  account  for  in  any  other  way  than  by 
an  action  of  the  nerves.  The  nerves  may  at  least  be  placed  in  a  prominent  position  among 
the  predisposing  causes  of  inflammation.  "Age  also  has  a  marked  influence  upon  the  process. 
Disturbances  of  nutrition  in  growing  children  lead  readily  to  inflammations  which  are  not 
likely  to  occur  in  adults,  such  as  affections  of  the  mucous  membranes  and  the  bones.  In 
old  age  the  power  of  resistance  to  invading  organisms  is  less  marked,  and  sepsis  is  more 
readily  produced.  Morbid  conditions  of  the  blood  (such  as  gout,  scurvy,  and  diabetes) 
subject  the  patient  to  inflammation  of  the  joints  and  of  the  mucous  membrane  and  the  skin. 
Climate  is  also  a  potent  factor. 

Inflammation  was  primarily  divided  into  several  varieties,  such  as  idio- 
pathic, traumatic,  sthenic,  and  asthenic.  These  terms  are  now  largely 
discarded.  Such  terms  as  "  hemorrhagic,"  "  parenchymatous,"  and 
"  interstitial  "  have  more  interest  for  the  pathologist  than  for  the  sur- 
geon. 

Pathology. — The  seat  of  inflammation  is  the  connective  substances 
principally — that  is,  those  parts  concerned  in  the  nutrition  of  the  body. 
If  we  take  the  connective  tissue,  we  find  these  changes  observed  in 
their  simplest  form.  The  first  change  noticed  is  in  the  blood-vessels. 
If  a  frog  be  paralyzed  by  curare  and  a  loop  of  intestine  be  drawn 
through  an  incision  made  in  the  abdominal  wall,  the  action  of  the  ves- 
sels can  readily  be  studied  during  the  inflammatory  process  excited  by 
the  exposure  of  the  peritoneum.  There  is  at  first  a  marked  active 
hyperemia.  The  vessels  are  distended  with  arterial  blood,  and  numer- 
ous capillaries  are  observed  which  before  were  invisible.  The  increased 
rapidity  of  the  blood-flow  lasts,  however,  but  for  a  short  time,  and  is 
followed  by  a  slowing  of  the  current,  which  soon  becomes  slower  than 
normal.     A   marked  chance  now  occurs  in  the  interior  of  the  small 


INFLAMMA  TION. 


47 


veins  and  capillaries.  Along  the  walls  of  the  veins  there  may  now  be 
noticed  an  accumulation  of  white  corpuscles,  which  increase  in  number 
to  such  an  extent  that  the  entire  vessel-wall  appears  to  be  lined  with 
them.  Presently  the  phenomena 
of  diapedesis  of  the  white  cor- 
puscles (Fig.  14)  takes  place,  and 
leukocytes  are  found  in  large 
numbers  in  the  surrounding  con- 
nective tissue.  At  the  same  time 
there  is  considerable  leakage  of 
fluid  or  blood-plasma  from  the 
vessels  into  the  meshes  of  the 
surrounding  tissue.  The  fluid 
coagulates,  and  in  the  fibrils  of 
fibrin  which  are  thus  formed  are 
found  the  white  corpuscles.  This 
is  known  as  "  exudation."  Fibrin 
is  formed  by  the  union  of  the 
fibrinogen  of  the  blood-plasma 
with  the  paraglobulin  and  fibrin- 
ferment  found  in  the  white  blood- 
corpuscles.  These  leukocytes,  in 
virtue  of  their  ameboid  move- 
ments, wander  freely  in  the  tis- 
sues,   and    the     exudation    then 

spreads  over  a  considerable  microscopic  area  (Fig.  15).  Many  of 
them  break  up  and  liberate  the  substances  necessary  for  the  process 
of  coagulation. 

It  will  be  seen  that  the  process  here  described  is  essentially  different 
from  hyperemia.     The  vessels  have  been  damaged  and  leak,  and  the 


I   V 

I 

"  •'/  '• 

1     © 

m 

V 

— The  blood-vessels  in  inflammation : 
Diapedesis  of  white  corpuscles. 


i 


^ 


W  ■< 


Fig.  is. — Ameboid  movements  of  a  leukocyte. 


■*•-:  y 


changes  in  their  power  to  conduct  the  blood  through  them  are  marked. 
The  rapidity  with  which  the  blood  flows  varies  greatly  in  different  parts 
of  an  inflamed  area.     On  the  periphery  the  velocity  of  the  current  is 


48  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

greatly  increased.  The  nearer  we  approach  the  central  point  of  an 
actively  congested  area,  the  slower  is  the  current ;  and  at  times  when 
the  tension  of  the  part  has  been  greatly  increased,  there  may  be  stasis 
or  stoppage  of  the  flow.  There  is  great  variability  in  the  rapidity  of 
the  flow  of  blood,  according  to  the  local  conditions. 

The  changes  seen  in  the  blood  in  simple  inflammations  are  not  im- 
portant, the  increase  in  the  number  of  white  corpuscles,  or  leukocytosis, 
being  more  characteristic  of  infective,  or  more  strictly  speaking,  sup- 
purative inflammations.1 

The  changes  seen  in  the  tissues  are  those  produced  by  the  great 
increase  in  the  cells  of  the  part.  The  cells  of  connective  tissue  are 
known  as  the  fixed  and  the  wandering  cells.  The  fixed  cells  are  stellate 
or  fusiform,  and  lie  hidden  between  the  fibers  which  constitute  the  prin- 
cipal portion  of  the  intercellular  substance.  In  addition  to  these  are 
the  small  round  cells,  containing  one  or  more  nuclei  and  a  granular 
protoplasm,  in  all  respects  resembling  the  white  corpuscles  of  the  blood. 
These  are  the  so-called  wandering  cells.  When  the  tissues  are  irritated 
or  inflamed,  these  cells  are  found  in  large  numbers.  When  the  theory 
of  cell-emigration  was  adopted  there  was  an  inclination  to  reject  the 
old  theory  of  cell-proliferation.  The  numerous  cells  found  in  a  part 
were  supposed  to  be  emigrated  leukocytes,  and  the  subsequent 
changes  found  in  the  part,  by  which  new  tissue  replaced  the  old,  were 
supposed  to  be  effected  largely  through  the  agency  of  the  wandering 
cells. 

After  an  inflamed  tissue  has  reached  this  stage,  we  find  that  the  cells 
of  the  part  predominate  over  all  other  elements.  The  intercellular 
substance  becomes  less  apparent,  the  fibers  disappear,  and  a  granular 
material  takes  their  place.  The  tissue  is  thus  considerably  modified  in 
its  physical  properties  ;  it  becomes  rigid  and  less  pliable,  and  at  the 
same  time  loses  its  tough  and  flexible  characteristics.  A  "  cake  "  forms, 
which  indicates  the  outline  of  the  inflamed  area.  The  tissue  thus 
formed  is  known  as  "  granulation-tissue,"  for  it  is  of  tissue  like  this 
that  the  granulations  seen  upon  the  open  surface  of  wounds  are  com- 
posed. When  the  inflammatory  process  begins  to  subside,  these  cells 
gradually  disappear :  some  wander  into  the  adjacent  lymphatics  and 
are  taken  back  into  the  circulation  again  ;  others  are  broken  down  and 
absorbed.  New  intercellular  substance  makes  its  appearance,  and, 
with  the  gradual  process  of  repair,  new  tissue  is  found  to  replace  any 
loss  of  substance  which  may  have  occurred  during  the  inflammatory 
process.  If  these  different  stages  follow  one  another  without  suppura- 
tion having  taken  place,  the  inflammation  is  said  to  have  terminated  by 
resolution.  The  same  series  of  processes  is  observed  in  wounds  heal- 
ing by  first  intention,  and  it  is  in  this  way  that  the  edges  of  a  wound 
become  adherent  and  finally  unite. 

There  has  been  much  dispute  about  the  functions  of  the  leukocytes.  When  Cohnheim 
first  brought  them  to  the  attention  of  the  profession,  he  assumed  that  they  performed  the 
duty  in  the  process  of  repair  hitherto  ascribed  to  the  cells  of  the  part.  The  fixed  cells  wqre 
thought  by  him  to  take  no  part  in  the  process  of  repair.  It  has,  however,  been  shown  that 
the  fixed  cells  undergo  active  changes,  by  means  of  which  cell-division  and  multiplication 

•  See  section  on  Pathology  of  the  Blood. 


INFLAMMATION. 


49 


occur.  In  the  nucleus  changes  known  as  karyokinesis  occur,  by  means  of  which  the  so- 
called  indirect  cell-division  takes  place  (Fig.  16).  Many  of  the  new  cells  seen  in  the  in- 
flamed part  are  the  offspring  of  such  changes.  It  is  these  cells  which  play  a  prominent  part 
in  the  process  of  repair.  It  is  now  thought  that  many  of  the  leukocytes  which  are  seen  in 
such  large  numbers  serve  as  pabulum  for  the  proliferating  fixed  cells,  and  that  others  play 


I 


1     ^ 


)  jg& 


»  d 


\~r* 


^3 


FlG.  16. — Changes  occurring  in  the  nucleus  of  a  cell  during  process  of  division  by  karyokinesis. 

the  role  of  scavengers,  owing  to  the  power  possessed  by  them  of  appropriating  particles  of 
foreign  bodies  or  bacteria  and  transporting  them  to  distant  points.  The  usefulness  of  the 
leukocytes  in  consuming  and  receiving  portions  of  broken-down  tissue  can  easily  be  under- 
stood, as  it  is  in  this  way  that  absorption  is  facilitated,  by  means  of  which  disposal  is  made 
of  dead  substances,  blood-clots,  exudations,  and  bacteria. 

Cells  which  are  specially  endowed  with  this  property  are  known  as  phagocytes  (Fig.  17), 


$  ** 


Fig. 


i7- 


-Phagocyte   from    exudate  of  cerebrospinal  meningitis,   containing   leukocytes  and 
cell-detritus. 


and  are  supposed  to  exercise  a  protective  influence  in  the  body.  This  theory  was  advanced 
by  Metschnikoff,  who  showed  that  in  those  diseases  in  which  the  tissues  were  succumbing 
to  the  bacteria,  no  micro-organisms  were  found  in  these  cells  ;  but  that  in  case  the  system  was 
able  to  throw  off  the  bacteria,  remains  of  destroyed  micro-organisms  were  found  in  the 
phagocytes. 

Metschnikoff  endeavored  in  this  way  to  explain  the  immunity  which  certain  tissues  have 
i 


5<D  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

for  certain  forms  of  bacteria.  Although  the  antibacterial  action  or  antitoxic  properties  of 
the  blood-serum  are  now  better  understood  than  when  this  theory  was  first  advanced,  the 
theory  oi  phagocytosis  still  lias  many  adherents,  and  it  is  probable  that  these  cells  play  a 
prominent  part  in  the  pathological  process  in  protecting  the  surrounding  tissue  from  the 
invasion  of  disease.  'These  are  the  principal  changes  observed  in  an  inflamed  area  when 
there  is  no  suppuration,  and  when  repair  follows  after  the  subsidence  of  the  more  prominent 
symptoms  of  inflammation  which  have  resulted  from  injury. 


Fin.  18. — Giant  cell  containing  glanders  bacilli  in  the  subcutaneous  tissue. 

Symptoms  of  Inflammation. — There  are  five  cardinal  symptoms 
of  inflammation — pain,  heat,  redness,  swelling,  and  impaired  function 
(dolor,  calor,  rubor,  tumor,  and  functio  laesa). 

These  symptoms  vary  greatly  in  different  forms  of  inflammation  or 
in  inflammation  of  different  tissues.  In  the  simple  inflammations — 
such,  for  instance,  as  that  following  a  fracture  of  the  leg — the  red  color 
is  not  so  marked  as  in  an  acute  septic  inflammation.  In  inflammations 
of  the  internal  organs  there  is  no  increase  of  heat  over  that  of  the 
surrounding  healthy  structures.  In  bone  there  is  at  first  no  swelling 
when  it  is  inflamed. 

The  rubor  or  redness  is  due  to  the  increased  determination  of  blood 
to  the  part.  In  acute  inflammations,  particularly  in  the  septic  forms, 
the  color  is  bright  red  or  scarlet.  An  incision  with  the  knife  brings  a 
quick  gush  of  bright  arterial  blood.  The  color  is  lighter  at  the  pe- 
riphery of  an  inflammatory  swelling,  and  deepens  toward  the  center, 
where  the  current  is  more  impeded  in  its  action.  In  very  severe  forms 
of  inflammation  the  congestion  is  often  excessive,  and  the  smaller 
vessels  are  overdistended  with  red  blood-corpuscles.  Under  these  cir- 
cumstances there  may  be  an  escape  of  the  red  corpuscles  as  well  as 
the  leukocytes  through  the  walls  of  the  vessels,  and  in  such  cases  they 
are  collected  together  in  little  groups,  forming  punctiform  ecchymoses. 
This  condition  is  seen  in  the  "  hemorrhagic  "  forms  of  inflammation. 
An  abundant  exudation  may  diminish  the  brightness  of  the  color  and 
give  it  a  yellowish  tinge.     The  color  of  an  inflamed  mucous  membrane 


INFLAMMA  TIO  N.  5  I 

is  much  deeper  than  that  of  the  skin,  owing  to  the  close  proximity  of 
the  blood-vessels  to  the  surface.  The  color  is  absent  in  bloodless  parts, 
as  the  cornea. 

The  tumor  or  swelling  is  due  to  the  exudation  poured  out  from 
the  vessels  into  the  inflamed  part.  This  collects  in  the  meshes  of  the 
tissue  or  is  poured  from  the  surface  of  the  membranes.  In  easily  dis- 
tensible parts  near  an  acute  inflammation  the  amount  of  fluid  exuded 
is  quite  large.  This  is  known  as  collateral  edema.  The  prepuce  and 
the  eyelids  are  often  greatly  swollen  even  where  the  amount  of  adjacent 
inflammation  is  slight.  In  the  thigh  we  may  have  exudation  and  swell- 
ing on  a  large  scale  following  fracture  of  the  bone  or  an  acute  osteo- 
myelitis. 

The  dolor  or  pain  is  due  to  the  pressure  on  the  terminal  branches 
of  the  nerves,  and  consequently  it  differs  greatly  according  to  the  dis- 
tensibility  of  the  part  or  to  the  amount  of  exudation  or  to  the  nerve- 
supply.  In  unyielding  tissue,  such  as  bone,  the  pain  is  at  first  most 
severe.  In  all  tissues  the  pain  is  more  severe  at  the  beginning  of  an 
inflammation,  while  the   tissues  are  in  process   of  being  stretched. 

Pain  is  of  different  kinds.  Throbbing  pain  is  due  to  the  extra 
pressure  exerted  by  the  arterioles  during  systole  in  somewhat  rigid 
and  sensitive  parts  like  the  fingers. 

Boring  pains  are  felt  in  chronic  inflammation  of  bone.  A  lancinating 
pain  suggests  the  breaking  down  or  tearing  apart  of  tissues  during  the 
approach  of  pus  to  the  surface,  and  is  suggestive  of  the  "  breaking  " 
of  an  abscess. 

Soreness  is  a  form  of  less  severe  pain  ;  it  is  due  to  an  acute  inflam- 
mation in  a  yielding  but  superficially  sensitive  structure.  The  boil  is 
the  proverbial  type  of  this  form  of  pain. 

Itching  is  always  said  to  be  a  good  sign,  and  correctly  so,  for  it  is 
the  residual  morbid  sensation  which  remains  when  pain  disappears. 
It  is  due  to  the  presence  of  the  products  of  exudation  in  the  vicinity 
of  the  terminal  nerve-branches. 

Some  portions  of  the  body  are  far  more  sensitive  than  others.  Fissure  of  the  anus  is  an 
example  of  severe  pain  caused  by  a  slight  disturbance  in  an  extremely  sensitive  locality. 
Pain  in  certain  organs  is  often  referred  to  distant  points.  Thus  the  pain  of  a  diseased  hip 
may  be  felt  in  the  knee.  Pain  at  the  neck  of  the  bladder  is  felt  at  the  meatus  of  the 
urethra. 

Calor  or  heat  is  due  to  the  increased  flow  of  blood  through  the 
inflamed  part.  The  amount  of  heat  generated  in  the  diseased  area  is 
extremely  small,  and  does  not  account  for  the  increased  warmth. 

The  fifth  and  last  symptom  of  inflammation  is  functio  la^sa.  A 
muscle  that  is  the  seat  of  an  inflammatory  exudation  is  rigid,  and  can- 
not contract  like  a  healthy  muscle.  Mucous  membranes  may  secrete 
a  much  greater  quantity  of  mucus  when  inflamed,  or  they  may  be 
unnaturally  dry.  The  special  senses  are  all  impaired  in  their  functions 
when  the  corresponding  organs  are  inflamed. 

Inflammation  may  terminate  either  in  resolution,  in  death  of  the 
part,  or  in  suppuration. 

Termination  by  resolution  occurs  when  the  various  symptoms  grad- 
ually subside  and  the  part  returns  to  its  normal  condition.  This  is  seen 
in  simple  inflammations  following  injury  when  the  process  of  repair  is 


52  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

well  under  way.  A  simple  inflammation  does  not  tend  to  spread,  and 
its  symptoms,  after  full  development  during  the  first  two  or  three  days, 
begin  gradually  to  disappear. 

If  the  congestion  of  the  blood-vessels  has  been  so  severe  as  to 
cause  a  stoppage  in  the  flow  of  blood,  or  stasis,  the  affected  area  will 
die  and  a  "  slough  "  is  formed ;  or  if  the  area  is  extensive  the  change 
is  called  "  gangrene."  The  dead  part  is  separated  from  the  live  tissue 
by  the  formation  of  a  line  of  demarcation  caused  by  a  suppuration  of 
the  adjacent  living  tissues.  If  the  dead  or  necrosed  area  is  small,  it 
may,  if  on  the  surface,  form  a  dry  scab,  under  which  repair  of  the  lost 
substance  will  take  place  without  suppuration.  If  it  is  in  the  interior 
of  the  body,  it  is  usually  called  an  "  infarction,"  and  may  shrivel  and 
be  replaced  by  cicatricial  tissue,  also  without  suppuration. 

Suppuration  occurs  only  in  connection  with  bacterial  infection,  and 
will  be  considered  under  that  head. 

Treatment. — The  treatment  of  simple  inflammation  is  directed 
chiefly  to  relieve  the  symptoms  and  favor  resolution — that  is,  to  pre- 
vent such  injury  to  the  tissues  as  may  lead  to  death  or  suppuration. 
Rest  is  one  of  the  most  important  agents  in  minimizing  the  amount 
of  damage  to  the  parts  from  injury.  This  tends  to  keep  down  the 
exaggeration  of  the  symptoms,  such  as  the  swelling  and  the  pain. 
These  may  be  relieved  also  by  the  application  of  heat  in  the  form  of 
a  poultice,  or  of  cold.  An  ice-bag  placed  upon  a  knee  which  has 
recently  been  sprained  will  relieve  the  pain  and  frequently  prevent  an 
undue  exudation  of  synovial  fluid  into  the  joint. 

The  soothing  action  of  cold  usually  makes  it  a  welcome  application. 
If  the  swelling  is  great,  and  the  circulation  is  sluggish,  the  color  dusky, 
and  the  temperature  of  the  part  low,  cold  is  not  indicated,  as  the  vital- 
ity of  the  part  may  thus  be  imperilled. 

Cold  can  be  employed  by  means  of  either  a  rubber  ice-bag  or  the 
ice-coil,  by  means  of  which  a  continuous  stream  of  cold  water  may 
exert  its  influence  upon  the  part. 

Heat  acts  differently  according  to  the  degree  used.  Warm  poul- 
tices favor  an  increase  of  hyperemia  and  consequent  flushing  of  the 
part.  The  exudation  may  thus  be  increased  until  pus  forms  ;  or  the 
flushing  of  the  part  with  fresh  blood-serum  may  produce  conditions 
unfavorable  to  the  growth  of  bacteria,  or  may  sweep  away  the  products 
of  exudation  and  thus  favor  absorption.  Greater  heat  constricts  the 
blood-vessels  ;  thus,  a  hot  poultice  frequently  applied,  or  the  hot 
douche,  will  sometimes  check  an  incipient  inflammation  ;  chronic  con- 
gestions are  often  greatly  relieved  in  this  way. 

Venesection  is  now  a  discarded  remedy,  but  was  not  without  value 
in  certain  critical  conditions.  Local  bloodletting  is  still  much  used  to 
relieve  the  dangerous  tension  caused  by  some  congestions,  or  to  favor 
the  resolution  of  obstinate  chronic  inflammations.  Leeching  is  an 
excellent  remedy  for  the  relief  of  local  pain,  and  has  also  a  stimulat- 
ing effect  upon  the  absorbents.  It  is  a  most  useful  means  of  relieving 
congestion  and  promoting  absorption  in  certain  cases,  and  would  doubt- 
less be  employed  oftener  were  nurses  properly  trained  to  the  applica- 
tion of  leeches.  In  some  injuries,  where  vessels  have  been  ruptured 
and  internal  hemorrhage  has  taken  place,  the  safety  of  a  limb  may  be 


INFLAMMA  TION.  5  3 

at  stake  when  the  swelling  of  inflammation  supervenes  upon  that  of 
the  injury.  The  skin  is  tense  and  shining,  the  color  is  dusky,  and  the 
blood  flows  slowly  back  into  its  channels  after  being  forced  away  by 
pressure.  This  condition  is  often  accompanied  by  severe  pain.  Under 
these  circumstances  free  incisions  are  indicated  to  relieve  the  passive 
hyperemia.  The  venous  blood  can  now  escape,  and  is  replaced  by 
fresh  arterial  blood  which  otherwise  could  not  have  entered  the  limb. 
The  relief  of  pressure  opens  the  collateral  vessels,  and  the  circulation 
is  once  more  restored.  Such  incisions  should  be  sufficiently  long 
and  deep  to  give  relief  to  tension.  They  should  be  carried  down 
through  the  skin  and  superficial  fascia,  and  through  the  muscular 
fascia  if  necessary.  If  done  with  thorough  aseptic  precautions,  a  sim- 
ple fracture  may  be  converted  into  a  compound  fracture  temporarily, 
and,  after  the  crisis  is  passed,  the  wound  may  be  closed  again  in  two 
or  three  days  if  desired.  The  superficial  scarifications  often  employed 
are  of  little  or  no  value.  If  it  is  desired  to  avoid  a  long  incision,  alter- 
nating short  incisions  may  be  substituted,  or  numerous  deep  punctures 
can  be  made  with  the  point  of  the  knife,  and  the  flow  of  blood  and 
serum  may  be  promoted  by  antiseptic  fomentations.  Moist  applica- 
tions upon  fresh  open  wounds  thus  made  often  pave  the  way  for  future 
suppurations.  The  large  incision,  with  dry  aseptic  gauze  dressing,  is 
therefore  the  safer  method. 

Counterirritation  is  of  much  value  in  chronic  forms  of  inflammation, 
and  may  be  applied  by  the  actual  cautery,  the  blister,  or  by  milder 
measures,  such  as  tincture  of  iodin  or  mustard  plasters.  The  actual 
cautery  is  still  often  used  in  chronic  tuberculosis  of  joints  or  other 
chronic  forms  of  joint-inflammation.  It  may  be  applied  by  the  Pa- 
quelin  cautery  on  several  isolated  points  or  in  crossing  lines.  The 
application  can  be  repeated  a  week  or  two  later.  Iodin  is  useful  when 
a  milder  and  more  continuous  irritation  is  desired.  The  part  to  which 
the  application  is  made  should  receive  two  coats  at  first.  The  iodin 
may  then  be  painted  on  daily  for  one  or  two  days,  after  which  it  is 
well  to  wait  a  day  or  two  for  the  irritation  thus  caused  to  subside 
before  repeating  the  application.  The  fly-blister  is  a  powerful  absorb- 
ent. If  such  an  effect  be  desired,  a  blister  about  one  inch  square  may 
be  applied,  and  two  or  three  days  later,  after  the  blister  thus  produced 
has  dried  and  the  skin  has  exfoliated,  a  second  blister  may  be  applied 
upon  the  same  spot.  This  usually  produces  a  marked  irritation  of  the 
skin,  extending  to  the  subcutaneous  tissue.  When  the  swelling  thus 
produced  is  absorbed,  the  old  infiltration,  enlarged  gland,  or  bursal 
effusion  also  frequently  disappears.  Dry  and  wet  cups  are  out  of 
fashion,  but  are  undoubtedly  valuable  agents  in  the  dispersion  of 
chronic  and  deep-seated  exudations  which  resist  the  ordinary  reme- 
dies. 

Compression  is  a  valuable  agent  to  keep  down  swelling  in  the  early 
stages  of  inflammation  and  to  produce  the  absorption  of  effusion  in 
its  later  stages.  It  must  be  applied  with  care  whenever  there  is  any 
question  as  to  the  integrity  of  the  circulation.  In  injuries  of  joints  the 
effusion  is  often  markedly  restrained  by  equable  pressure,  and  the 
period  of  convalescence  is  thus  diminished.  Pressure  will  cause  old 
inflamed  glands  or  other  chronic  and  rebellious  swellings  to  disappear. 


54  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

To  be  applied  efficiently  to  any  portion  of  a  limb,  it  should  be  used  in 
conjunction  with  a  splint.  Thus,  in  the  case  of  housemaid's  knee,  a 
ham  splint  having  been  applied,  a  compressed  sponge  of  appropriate 
size  can  be  bandaged  firmly  to  the  swollen  bursa,  after  which  moisture 
should  be  applied  to  the  sponge  to  increase  the  local  pressure.  The 
whole  knee-joint  may  be  firmly  compressed  in  this  way. 

Rest  is  essential  in  the  treatment  of  inflammation.  For  this  pur- 
pose the  patient  should  be  confined  to  bed  if  the  inflamed  part  cannot 
be  rested  in  any  other  way.  In  acute  inflammations  of  the  bladder 
such  a  precaution  is  essential.  The  lower  extremity  should  be  ele- 
vated, and,  indeed,  it  may  be  said  that  elevation  of  the  inflamed  part, 
wherever  situated,  is  a  valuable  adjunct  to  the  treatment.  In  inflam- 
mation of  the  prostate  gland  elevation  of  the  hips  often  gives  marked 
relief  to  the  symptoms. 

Physiological  rest  of  such  organs  as  the  bladder  or  the  brain  is  most  valuable  in  many- 
cases.  In  some  brain  injuries  absolute  mental  quietude  is  essential  for  many  weeks  after 
the  accident.  In  certain  forms  of  chronic  cystitis  which  do  not  yield  to  other  treatment,  an 
opening  into  the  bladder  by  cystotomy  will  give  the  needed  rest,  and  is  often  followed  by 
prompt  amelioration  of  the  symptoms. 

Massage. — After  the  inflammatory  swelling  has  subsided  the  mus- 
cles are  found  to  be  smaller  and  less  pliable,  the  tendons  do  not  move 
easily  in  their  sheaths,  and  the  capsules  of  joints  are  matted  together 
and  do  not  unfold  readily.  The  limb  is  stiff  and  unserviceable ; 
attempts  to  use  it  are  followed  by  increase  of  pain,  and  frequently  of 
some  of  the  other  of  the  old  symptoms  from  which  it  has  suffered.  It 
is  in  this  stage  that  massage  is  of  value.  Massage  is  deep  rubbing,  and 
is  a  great  advance  over  the  superficial  rubbing  produced  by  liniments. 
By  massage  the  deep-seated  exudations  are  softened  and  the  circula- 
tion in  the  deep  lymphatics  is  re-established,  so  that  absorption  goes  on 
again.  The  circulation  of  the  blood  also  becomes  more  active,  so  that 
the  disabled  parts  receive  proper  nourishment.  The  term  "  rubbing  " 
includes  kneading,  pressure,  and  such  manipulations  as  will  transform 
rigid  into  limber  structures.  Passive  motion  is  a  valuable  adjunct  to 
massage,  as  it  stretches  muscles  and  thus  restores  their  function.  It 
also  loosens  the  shrunken  capsule,  and  enables  the  tendon  to  slide  to 
and  fro  again  through  its  sheath.  Unless  the  parts  have  been  softened 
sufficiently  by  massage,  passive  motion  may  lacerate  the  imperfectly 
organized  exudations  and  cause  hemorrhage  and  inflammation,  which 
will,  of  course,  retard  the  process  of  convalescence.  It  should  there- 
fore be  used  only  after  the  acute  symptoms  of  inflammation  have  sub- 
sided and  massage  has  paved  the  way  for  bending  and  stretching  the 
affected  tissues.  In  the  aged  and  feeble  the  disease  of  a  limb  or  a  joint 
may  lead  to  permanent  disability  if  the  important  aids  to  the  treatment 
of  inflammation  are  neglected.  In  cases  of  injury  awaiting  trial  in 
actions  of  tort,  this  portion  of  the  treatment  is  usually  neglected,  and 
one  has  an  opportunity  to  see  how  long  a  limb  may  remain  disabled  if 
proper  measures  are  not  taken  to  restore  the  function  of  the  part. 

Constitutional  Treatment. — The  old  heroic  methods  of  purgation 
and  emetics  and  resolvents  have  passed  away,  and  the  "  antiphlogistic  " 
treatment  has  been  superseded  by  the  antiseptic  treatment,  and  it  is 
now  generally  recognized  that  supporting  measures  are  of  more  impor- 


INFLAMMATION.  55 

ance  than  the  old  depleting  system.  Inflammation  means  damage,  and 
the  constitutional  disturbance  which  precedes  or  accompanies  it  is 
usually  in  the  nature  of  either  shock  or  fever.  Both  of  these  conditions 
lower  the  vitality  of  the  system  and  render  it  less  capable  of  exerting 
its  natural  powers  of  recovery.  Every  opportunity  should  be  given  it 
to  do  this.  Rest  to  the  body  is  therefore  important,  as  well  as  rest  to 
the  injured  member.  There  should  be  no  waste  of  tissue  or  strength 
allowed,  as  all  is  needed  for  repair. 

The  patient  should  be  kept  quiet  during  the  period  of  pyrexia,  as 
at  this  time  the  system  is  peculiarly  susceptible  to  outward  influences, 
and  complications  of  various  kinds  may  in  this  way  be  avoided.  Suit- 
able rest  can  best  be  obtained  in  bed  if  there  is  much  fever,  and  under 
such  conditions  no  patient  should  be  allowed  to  be  the  judge  of  what 
suits  his  own  peculiar  temperament.  Proper  ventilation  of  the  sick- 
chamber  is  essential,  but  neither  the  nurse  nor  the  patient  should  be 
allowed  to  decide  how  this  should  best  be  accomplished. 

Diet  is  of  great  importance,  and  should  be  as  nourishing  as  is  pos- 
sible under  existing  conditions.  The  stomach  should  be  supplied  with 
nutritious  and  quite  digestible  food.  Milk  is  the  most  valuable  of  all 
liquid  forms  of  food,  and  can  be  readily  digested  at  all  periods  of  life, 
in  spite  of  the  popular  prejudice  that  it  is  apt  to  "  disagree."  Care 
should  be  taken  to  have  a  good  article,  and  if  there  is  any  doubt  as 
to  its  quality,  it  should  be  sterilized.  Mixed  with  lime-water  or  bicar- 
bonate of  potassium,  milk  is  less  liable  to  coagulate  and  to  cause  indi- 
gestion, and  if  given  at  first  in  this  way  and  in  small  quantities,  it  can 
usually  be  well  borne  even  by  those  who  are  unaccustomed  to  it  as  an 
article  of  diet.  It  is,  however,  contraindicated  after  operations  upon 
the  perineum  or  rectum,  or  in  any  case  when  it  is  important  to  avoid 
for  several  days  a  movement  of  the  bowels,  owing  to  the  large  amount 
of  fecal  residue  which  remains  after  it  has  been  digested.  A  liquid 
diet  without  milk  should  be  employed  under  these  circumstances. 
Meat-broths  should  then  be  substituted,  and  in  small  quantities,  some 
of  the  lighter  forms  of  solid  food  may  be  given,  such  as  eggs,  or  finely 
chopped  meat,  or  beef-  or  chicken-jelly.  Tea,  cocoa,  and  coffee  in 
small  quantities  relieve  the  monotony  of  this  form  of  diet.  Pure  water 
should  always  be  given,  and  the  nurse  should  be  reminded  that  this  is 
an  essential  article  on  the  diet-list.  When  given  in  small  quantities  and 
frequently,  it  favors  heat-dissipation,  helps  to  bring  about  lysis,  and 
contributes  greatly  to  the  comfort  of  the  patient.  In  a  few  days  after 
a  surgical  operation  a  varied  solid  diet  may  be  ordered  in  the  majority 
of  cases.  When  food  cannot  be  retained  by  the  stomach,  nutrient 
enemata  may  be  administered.  Enemata  of  water  or  of  normal  salt- 
solution  often  give  great  relief  to  thirst.  A  few  drops  of  laudanum 
may  be  added  to  an  enema  if  there  is  any  doubt  about  the  patient  being 
able  to  retain  it. 

Alcoholic  stimulants  are  valuable  during  fever  if  the  pulse  shows 
signs  of  weakness.  They  are  a  safeguard  against  sepsis.  The  stom- 
ach should,  however,  be  carefully  watched  during  their  administration. 
Many  individuals  who  are  wholly  unaccustomed  to  the  use  of  alcohol 
bear  it  well  in  the  septic  forms  of  fever.  Then  alcohol  becomes  a  food, 
and  one  of  the  most  valuable  kind.     During  convalescence  light  wines 


56  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

or  beer  will   prove  valuable  aids  in  restoring  strength,  and  are  often 
preferable  to  tonics. 

Antipyretics  have  little  permanent  influence  upon  fever,  and,  owing 
to  their  debilitating  effect  upon  the  heart's  action,  are  usually  contra- 
indicated  in  surgical  cases.  They  may,  however,  be  used  to  relieve 
pain,  particularly  of  a  spasmodic  character,  and  those  forms  of  pain  or 
spasm  which  recur  at  certain  regular  intervals.  They  may  then  be 
serviceable  in  breaking  up  an  annoying  complication  of  this  nature. 

Mercury  was  formerly  used  with  great  freedom  in  all  inflammatory  processes,  as  it  was 
supposed  to  exert  a  resolvent  action  upon  fibrinous  exudation.  Its  use  has,  with  justice, 
been  very  generally  discarded  at  the  present  time. 

Purgatives  were  also  used  freely  under  the  antiphlogistic  system. 
They  are  now  indicated  only  as  a  preventive  against  the  storing  up  in 
the  intestinal  tract  of  materials  likely  to  lead  to  auto-inoculation.  They 
exert  a  derivative  action  in  threatening  inflammation  or  congestions  of 
the  meninges  of  the  brain,  as  they  relieve  the  tension  of  the  circulation 
and  remove  all  sources  of  reflex  irritation  from  the  intestinal  canal. 

In  threatening  peritonitis  laxatives  are  indicated  to  restore  the  nor- 
mal peristaltic  movements  and  to  act  upon  the  secreting  powers  of  the 
intestinal  mucous  membrane,  and  thus  draw  freely  upon  any  fluids  that 
may  exist  in  the  peritoneal  cavity  in  the  so-called  "  dead  spaces." 

Diaphoretics  are  but  little  used  in  this  condition.  Mild  diaphoresis  is  of  value  in 
moderating  fever  and  thus  contributing  to  the  comfort  of  the  patient.  The  judicious  use 
of  water  as  a  drink,  alone  or  combined  with  some  mild  drug,  such  as  sweet  spirits  of  niter, 
not  only  has  this  action,  but  is  also  sedative  and  diuretic. 

Anodynes  are  most  valuable  in  the  treatment  of  inflammation,  for 
they  not  only  relieve  the  most  disagreeable  symptom  of  inflammation 
— namely,  pain — but  give  relief  to  the  malaise  of  fever,  and  thus  favor 
repose.  Opium  in  the  form  of  morphin  is  perhaps  the  most  reliable  of 
all  anodynes.  When  a  moderate  action  only  is  required,  it  can  be 
given  by  the  mouth  in  doses  of  \  to  \  of  a  grain.  If  there  is  any 
question  as  to  the  ability  of  the  stomach  to  retain  it,  or  if  it  is  dis- 
turbed in  its  action  by  the  drug,  then  the  opiate  may  be  given  by  the 
rectum  in  a  suppository.  Subcutaneous  injections  of  morphin  are  to 
be  used  only  when  the  pain  is  severe  or  a  rapid  action  is  essential.  In 
private  practice  the  administration  of  a  subcutaneous  injection  of  mor- 
phin should  be  a  rare  occurrence  with  the  surgeon.  Occasionally 
alarming  symptoms  of  heart-failure  are  produced,  perhaps  by  the  in- 
jection of  the  fluid  directly  into  a  vein,  or  from  idiosyncrasy.  The 
greater  danger  lies  in  the  "  habit,"  so  readily  acquired  by  patients.  The 
subcutaneous  injection  of  morphin  may  be  used  in  the  first  twenty-four 
hours  after  an  operation,  and  for  one  or  two  nights  after  a  painful  oper- 
ation, but  it  should  never  become  a  routine  method  of  treatment. 

Bromid  of  potassium  will  often  relieve  many  attacks  of  so-called 
"pain,"  which  are  really  nothing  more  than  discomfort  and  restlessness. 
Neuralgic  and  spasmodic  pain  can  be  relieved,  as  shown  above,  by 
phenacetin.  Sulfonal  and  trional  are  both  useful  as  hypnotics,  the 
latter  acting  rather  more  rapidly  than  the  former ;  but  both  are  quite 
uncertain  in  their  action.  Chloral  in  small  doses,  5  to  7  grains,  can  be 
employed  when  other  remedies  fail ;  but  care  should  be  taken  that 
patients  do  not  become  too  accustomed  to  the  dose. 


LOCAL    INFECTION  AND   ITS    TERMINATIONS.  57 

Tonics  are  indicated  after  fever  has  subsided.  It  is  useless  to  give 
them  during  pyrexia,  as  they  simply  aid  convalescence,  but  cannot 
prevail  over  an  unfavorable  condition.  In  case  of  fever  they  become 
an  additional  burden  to  the  stomach.  They  are  especially  indicated  in 
those  cases  where  the  appetite  flags,  and  where  it  is  desirable  for  various 
reasons  not  to  recommend  the  use  of  alcohol.  A  young  and  healthy 
patient  will  convalesce  from  an  injury  or  an  operation  under  a  generous 
diet  without  the  aid  of  either. 

On  discharging  a  patient,  careful  directions  should  always  be  given 
as  to  the  regulation  of  the  mode  of  life  and  the  precautions  needed  in 
the  care  of  local  conditions. 

The  average  patient  regards  an  operation  as  a  panacea  which  enables  him  afterward  to 
do  as  he  pleases.  Many  an  important  case,  conducted  with  great  skill  through  the  critical 
stages  of  healing,  has  finally  come  to  grief  through  the  neglect  of  some  simple  precautions 
by  the  patient  himself.  A  convalescent  is  a  man  relieved,  perhaps,  from  some  grave  disease, 
but  for  the  time  being  with  susceptibility  to  outward  conditions  to  which  previously  he  has 
been  a  stranger. 

LOCAL  INFECTION  AND  ITS  TERMINATIONS. 

That  form  of  inflammation  which  is  due  to  the  action  of  bacteria  is 
called  infective  inflammation.  It  differs  markedly  from  simple  inflam- 
mation in  the  severity  of  many  of  its  symptoms.  One  of  the  most 
characteristic  features  of  septic  inflammation  is  its  tendency  to  spread. 
Simple  inflammation  involves  a  certain  area  in  a  short  space  of  time, 
according  to  the  amount  of  injury  inflicted,  and  then  steadily  subsides. 
Septic  inflammation  may  spread  indefinitely,  and  there  is  no  certainty 
as  to  the  extent  of  area  which  it  may  cover.  The  color  of  infective 
inflammation  is  also  quite  characteristic.  The  bright-red  blush  stands 
out  in  strong  contrast  to  the  surrounding  tissues.  All  the  symptoms 
are  usually  more  pronounced,  as  the  inflammation  is  essentially  an 
acute  one.  There  is,  however,  great  variability  in  the  symptoms,  and 
in  some  of  the  most  malignant  forms  of  spreading  sepsis  there  may  be 
but  little  change  in  the  color,  the  parts  assuming  the  appearance  of 
edema.  The  constitutional  disturbance  is  always  well  pronounced,  and 
goes  hand  in  hand  with  the  local  conditions.  Septic  inflammation 
usually  terminates  in  suppuration. 

The  organisms  which  are  most  commonly  found  in  these  conditions 
are  known  as  the  pyogenic  organisms.  They  produce  chemical 
changes  in  the  tissue  by  the  formation  of  a  toxic  substance  or  poison. 
The  substances  exert  a  peptonizing  action  upon  the  cells  of  the  part, 
and  cause  a  coagulation-necrosis  or  death  of  the  tissues  in  the  immedi- 
ate neighborhood  of  a  group  of  microbes,  and  bring  about  in  the  sur- 
rounding tissues  a  reaction  which  softens  them  and  changes  them  into 
pus.  In  this  way  the  affected  area  is  separated  from  the  rest  of  the 
body,  and  when  the  pus  escapes  the  products  of  disease  are  discharged 
with  it.  Under  less  favorable  conditions  the  reaction  is  less  effective, 
the  organisms  continue  to  spread  in  the  surrounding  parts,  and,  al- 
though suppuration  may  take  place,  the  walls  of  the  suppurating  cavity 
contain  bacteria  which  are  still  in  active  growth  and  are  invading  new 
regions. 

The  most  common  forms  of  bacteria  found  in  suppuration  are  the 


58  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

pyogenic  cocci,  viz. :  I.  The  Staphylococcus  pyogenes  aureus,  albus, 
citreus,  and  epidermidis  albus.  2.  The  Streptococcus  pyogenes.  (See 
Chapter  I.)  In  addition  to  these,  there  is  a  variety  of  micro-organisms 
which  less  frequently  are  the  cause  of  suppuration. 

The  Bacillus  pyocyancus  is  an  organism  found  in  green  and  blue  pus. 
It  is  not,  strictly  speaking,  a  pus-producing  organism,  and  is  generally 
associated  with  some  other  form  of  pyogenic  coccus.  The  characteris- 
tic greenish-blue  color  is  usually  found  on  the  outer  margins  of  the 
stained  dressings.  The  Bacillus  pyogenes  fcetidus  is  found  in  the  offen- 
sive abscesses  in  the  neighborhood  of  the  rectum.  The  Micrococcus 
tetragenus  has  been  found  in  acute  abscesses  ;  the  inflammation  pro- 
duced by  it  is  not  usually  severe,  but  is  somewhat  prolonged. 

The  Bacillus  coli  communis,  or  the  colon  bacillus,  is  found  in  normal 
discharges  from  the  alimentary  canal.  It  is  found  principally  in  the 
large  intestine.  It  is  a  source  of  suppuration  in  parts  liable  to  infection 
from  these  regions  of  the  body. 

This  organism  is  found  in  active  growth  in  suppurative  and  gangrenous  appendicitis, 
and  has  also  been  found  in  other  forms  of  perforative  peritonitis,  and  in  suppurative  proc- 
esses in  the  peritoneal  cavity.  Inasmuch  as  it  is  evacuated  with  the  discharges,  it  can  be 
obtained  in  cultures  taken  from  the  skin  in  the  neighborhood  of  the  anus,  the  vulva,  and 
occasionally  the  prepuce.  It  consequently  may  be  introduced  by  instruments  into  the  genito- 
urinary tract,  and  become  a  source  of  suppuration  along  this  route,  producing  cystitis  and 
pyelonephritis. 

Other  organisms,  under  favorable  conditions,  may  lead  to  suppura- 
tion, such  as  the  gonococcus,  the  pneumococcus,  the  typhoid  bacillus, 
and  the  organisms  which  produce  the  various  forms  of  traumatic 
infective  disease. 

The  Streptococcus  crysipclatis  is  now  regarded  as  identical  with  the 
Streptococcus  pyogenes.  It  does  not  usually  produce  suppuration,  but 
may  be  the  cause  of  minute  cutaneous  abscesses  or  the  spreading 
forms  of  subcutaneous  inflammation,  known  as  phlegmonous  ery- 
sipelas. 

The  Bacillus  tuberculosis  does  not  cause  the  formation  of  pus,  ex- 
cept possibly  in  exceptional  cases.  It  is  the  organism  which  causes 
what  is  commonly  known  as  cold  abscess. 

The  Amceba  coli  is  a  protozoon  found  frequently  in  the  intestinal 
canal,  principally  in  tropical  climates.  It  is  associated  with  certain 
forms  of  dysentery,  and  under  these  circumstances  may  produce 
abscess  of  the  liver.  The  contents  of  such  abscesses  are  a  thick, 
brownish-red  material,  the  products  of  broken-down  liver-tissue  rather 
than  true  pus.  When  the  latter  is  found,  there  is  probably  a  mixed 
infection. 

The  question  whether  suppuration  can  be  established  without  the 
intervention  of  bacteria  is  one  about  which  there  has  been  much  dis- 
pute. It  is  now  pretty  definitely  settled  that  clinically  we  do  not  obtain 
suppuration  in  any  other  way  than  through  the  agency  of  micro-organ- 
isms.    (See  Chapter  I.) 

Immunity. — The  pyogenic  bacteria  do  not  produce  suppuration 
in  the  body  whenever  introduced  into  it.  It  is  only  under  certain 
favorable  conditions  that  this  is  accomplished. 

Many  bacteria  are  rapidly  absorbed  from  the  point  of  entrance — 


LOCAL   INFECTION  AND   ITS    TERMINATIONS.  59 

that  is,  taken  up  into  the  circulation  and  swept  into  different  parts  of 
the  body  before  they  have  an  opportunity  to  grow  locally.  The  rapid- 
ity with  which  they  are  eliminated  from  the  system  is  often  remarkable. 
They  appear  to  be  actually  destroyed  in  the  blood-serum  itself,  in 
virtue  of  a  substance  ("  defensive  proteid,"  "  nuclein  ")  which  it  con- 
tains, that  exerts  a  germicidal  action  upon  them.  This  substance  is 
soluble  only  in  an  alkaline  medium,  and  consequently  it  is  necessary 
that  the  serum  should  be  alkaline  in  order ,  to  possess  this  power. 
This  substance  is  said  to  be  derived  largely  from  the  leukocytes,  which 
appear  to  have  the  power  also  of  exerting  a  protective  influence  in 
virtue  of  their  phagocytic  action. 

The  German  school  relies  chiefly  upon  the  bactericidal  powers  of 
the  blood-serum  as  a  protective  agent.  The  French  school  lays  more 
stress  upon  the  theory  of  phagocytosis.  It  is  probable  that  local 
infection  is  resisted  by  the  accumulation  of  leukocytes  at  the  point 
of  invasion,  and  that  their  protective  powers  are  exerted  partly  in 
virtue  of  their  phagocytic  action  and  partly  by  a  chemical  substance 
given  off  by  them  (germicidal  proteid).  It  seems  also  probable  that 
protection  against  general  infection  is  exerted  by  the  blood-serum 
aided  by  the  chemical  substances  given  off  by  increased  numbers  of 
leukocytes. 

The  attraction  of  leukocytes  to  a  point  of  infection  appears  to  be  due  to  a  power  of 
attracting  cells,  known  as  chemotaxis,  a  chemical  attraction  or  irritation  produced  by  the 
proteids  of  the  bacteria. 

After  introduction  into  the  body,  bacteria  are  often  found  at  distant 
points,  as  the  lymphatics  of  the  diaphragm  or  the  capillaries  of  viscera. 
Here  they  are  observed  frequently  in  the  leukocytes  of  the  circulating 
blood  or  in  the  endothelium  of  the  capillaries,  the  cells  of  which  seem 
to  possess  active  phagocytic  properties.  Those  not  destroyed  may 
be  eliminated  by  the  kidneys,  through  the  mucous  membrane  of  the 
intestines,  or  even  through  the  respiratory  organs.  Bacteria  have  also 
been  found  in  the  perspiration  of  individuals  suffering  from  septicemia. 

Among  the  conditions  favorable  for  infection  is  the  amount 
or  dose  of  the  poison  received  into  the  system.  The  experiments 
of  various  observers  have  shown  that  a  very  large  number  of  bacteria 
may  be  injected  without  producing  any  result.  Watson  Cheyne  found 
that  it  was  necessary  to  inject  a  dose  of  1,000,000,000  of  the  Staphylo- 
coccus pyogenes  aureus  into  the  muscles  of  a  rabbit  in  order  to  pro- 
duce a  fatal  result.  As  the  human  being  is  not  very  susceptible  to 
the  pyogenic  organisms,  considerable  numbers  can  be  left  in  a  wound 
without  producing  evidences  of  their  presence.  Under  varying  influ- 
ences the  virulence  of  bacteria  may  be  greatly  increased  or  dimin- 
ished, and  consequently  the  dose  of  any  given  organism  may  vary 
considerably. 

The  state  of  the  tissues  in  which  the  organisms  are  arrested  is  an 
important  factor  also  in  the  question  of  suppuration.  A  diminution  in 
the  vitality  of  a  part  furnishes  a  soil  favorable  for  bacterial  growth. 
Anemic  animals  resist  inoculation  with  the  aureus  much  less  vigor- 
ously than  those  in  health.  This  is  in  accord  with  the  well-recognized 
clinical  fact  that  furunculosis  is  a  sign  of  a  debilitated  condition  of  the 
system. 


60  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Slight  injuries  appear  to  favor  infection  more  readily  than  the 
severer  forms,  in  which  the  inflammatory  reaction  is  vigorous  and 
protective  in  its  influence.  Osteomyelitis  and  tuberculosis  of  the 
bones  find  their  starting-points  in  slight  bruises  in  the  bones  in  chil- 
dren who  are  run  down  or  over-fatigued.  Such  diseases  are  never 
observed  as  a  complication  of  simple  fractures.  The  pressure  of  a 
foreign  body  may  be  the  source  of  an  irritation  which  paves  the 
way  for  a  bacterial  infection.  Obstructions  of  the  secretions,  such 
as  milk  in  the  puerperal  breast,  are  predisposing  causes  of  sup- 
puration. Whether  the  presence  of  sugar  in  the  blood  directly  favors 
the  action  of  the  pyogenic  cocci  is  uncertain.  It  is  more  probable 
that  the  diminished  vitality  of  the  system  is  the  favoring  element. 
Those  addicted  to  the  excessive  use  of  alcohol  are  especially  suscep- 
tible to  infection.  A  feeble  circulation,  such  as  is  seen  in  hypostatic 
congestions,  favors  a  local  infection,  as  does  also  the  impairment  of 
the  innervation  of  a  part.  The  healthy  peritoneum  can  absorb  large 
numbers  of  bacteria  ;  but  when  injured  in  such  a  way  that  its  power 
of  absorption  is  seriously  disturbed,  the  conditions  for  infection  are 
most  favorable. 

Racial  peculiarities,  although  they  play  a  prominent  part  in  pre- 
disposition to  certain  diseases,  do  not  exert  much  influence  one  way  or 
the  other  on  suppuration.  The  same  may  be  said  of  locality,  although 
instances  of  certain  forms  of  infective  inflammation  have  been  credited 
to  certain  localities,  such  as  osteomyelitis  in  Switzerland  and  Germany. 
Less  importance  is  attached  to  the  season  of  the  year,  as  an  element 
in  infection,  than  was  given  it  before  the  antiseptic  era. 

The  possibilities  of  auto-infection  should  always  be  borne  in  mind. 
Park  has  dwelt  upon  the  danger  of  infection  from  this  source,  and  the 
importance  of  due  attention  to  the  excretions,  particularly  those  of  the 
intestinal  canal. 

I/Ocal  Action  of  Pyogenic  Organisms. — When  the  conditions 
for  suppuration  are  favorable,  if  a  culture  of  the  staphylococcus  be 
injected  into  the  tissues,  the  bacteria  multiply  rapidly  and  invade  the 
intercellular  substance  and  the  pre-existing  cells  of  the  part.  The  con- 
ditions found  in  acute  inflammation  soon  present  themselves.  Exuda- 
tion and  emigration  of  leukocytes  begin,  and  enormous  numbers  of  poly- 
nucleated  leukocytes  are  found  between  the  connective-tissue  fibers. 

The  cocci  show  a  tendency  to  aggregation  in  groups,  and  form  a 
more  or  less  continuous  mass  with  the  infiltration  of  leukocytes.  On 
the  second  or  third  day  the  granulation-tissue  begins  to  soften  in  the 
center,  as  a  result  of  the  coagulation-necrosis  and  consequent  breaking 
down  of  tissue  produced  by  the  action  of  bacteria  and  the  abundant 
exudation.  At  the  periphery  of  the  inflamed  mass  the  coccus  and 
leukocyte  infiltration  continues  to  spread ;  the  cocci  grow  in  thick  col- 
umns, with  small  groups  here  and  there  along  their  borders,  which 
groups  separate  and  grow  into  the  surrounding  tissue  (Fig.  19).  In  this 
way  local  suppuration  or  abscess-formation  is  established,  and  by  the  con- 
tinued growth  of  the  bacteria  burrowing  of  pus  may  be  brought  about. 

There  is  a  marked  difference  between  the  action  of  the  staphylococ- 
cus and  that  of  the  streptococcus.  The  latter  does  not  possess  the 
tendency  to  promote  local  suppuration.     It  creeps  rapidly  through  the 


LOCAL    INFECTION  AND   ITS    TERMINATIONS.  6 1 

tissues,  and  produces  in  this  way  a  spreading  inflammation.  It  exerts 
a  less  active  peptonizing  action  upon  the  tissues  than  does  the  aureus. 
When  deprived  of  oxygen,  the  peptonizing  action  comes  out  more 
strongly.  Consequently,  under  favoring  conditions  it  might  be  ex- 
pected to  cause  suppuration,  and  this  action  it  does  exert  during  the 
later  stages  of  the  period  of  its  invasion  of  the  tissues. 

The  staphylococcus,  owing  to  its  mode  of  growth,  tends  to  remain 
localized,  and  produces  inflammations  with  well-defined  areas.  It  is 
the  organism  most  frequently  found  in  the  typical  abscess.  The  strep- 
tococcus, although  it  may  cause  suppuration,  is  identified  with  those 
forms  of  inflammation  which  invade  the  tissues  through  the  lymph- 
spaces  and  vessels.  It  is  found  in  those  septic  inflammations  which  are 
the  result  of  wounds  received  during  dissections  or  operations  on  highly 
septic  tissues.  Such  inflammations  are  accompanied  by  lymphangitic 
involvement  of  the  adjacent  lymphatic  glands  and  by  marked  constitu- 
tional disturbance.  The  organism  gains  an  entrance  into  the  circulation 
readily,  and  where  conditions  are  favorable  may  multiply  enormously, 
producing  that  grave  form  of  infection  known  as  septicemia.  If  its 
advance  has  been  resisted  successful!)',  it  may  remain  more  or  less 
localized,  and  will  then  probably  produce  that  type  of  suppuration 
known  as  spreading  abscess,  or  purulent  infiltration.  These  forms  of 
suppurative  inflammation  are  known  as  phlegmonous  inflammation  or 
phlegmonous  erysipelas. 

Infective  inflammation  may  also  terminate  in  death  of  the  part.  This 
occurs  in  the  more  virulent  forms  of  infection,  where  the  protective  in- 
fluence of  the  serum  and  the  cells  is  incapable  of  staying  the  progress 
of  infection.  The  toxic  substances  produced  by  the  cocci  are  found  in 
great  abundance,  and  destroy  the  tissues  with  which  they  come  in  con- 
tact before  suppuration  can  be  established ;  considerable  portions  of 
tissue  necrose,  and  extensive  sloughing  or  gangrene  occurs.  The  rap- 
idly spreading  gangrene  following  complicated  fractures  or  wounds 
poisoned  by  splinters  of  wrood  or  other  substances  are  examples  of 
this  type  of  inflammation,  which,  fortunately,  is  rare. 

Septic  inflammation  of  light  degree  may  terminate  by  resolution. 
This  is  seen  in  wounds  that  have  not  been  treated  by  careful  antiseptic 
methods,  and  was  common  before  the  days  of  antisepsis.  For  a  few 
days  the  edges  of  the  wound  are  red  and  swollen  and  there  is  more  or 
less  fever.  It  was  formerly  considered  the  type  of  traumatic  inflamma- 
tion, and  was  supposed  to  be  essential  to  repair.  Such  an  inflammation 
may,  however,  subside  with,  at  the  most,  a  little  seropurulent  discharge 
from  the  stitch-holes. 

Threatening  suppuration  may  be  prevented  by  a  prompt  use  of  the 
knife,  which  exposes  the  infected  area  and  enables  the  surgeon  to  apply 
antiseptic  agents  directly  to  the  infected  tissues. 

In  the  more  serious  forms  of  spreading  sepsis  free  incisions  are  in- 
dicated, followed  by  the  application  of  antiseptic  poultices,  which  favor 
a  free  flow  of  fluid  from  the  part,  thus  enabling  the  tissues  to  throw 
off  the  virus.  Suppuration,  it  should  always  be  remembered,  is  Nature's 
method  of  ridding  the  infected  parts  of  the  morbid  substances.  With 
the  formation  of  pus,  liquefaction  of  the  tissues  occurs,  and  with  its 
discharge  the  "  peccant  humors  "  are  eliminated  from  the  body. 


CHAPTER    III. 

SUPPURATION;    ABSCESS;    ULCER;    SINUS;    FISTULA. 

SUPPURATION. 

Suppuration  takes  place  in  the  tissues  by  virtue  of  the  peculiar 
peptonizing  or  digestive  action  which  the  micro-organisms  exert  upon 
them,  and  also  as  the  result  of  the  more  or  less  complex  changes 
which  occur  in  them  in  their  efforts  to  oppose  bacterial  invasion.  It 
is  one  of  the  manifestations  of  the  resistance  of  tissue  to  the  presence 
of  poisons  (Thayer).  The  organism  more  frequently  concerned  in 
suppuration  is  the  Staphylococcus  pyogenes  aureus  and  other  mem- 
bers of  this  group.  The  points  of  entrance  of  these  organisms  into 
the  body  vary  greatly.  In  operative  surgery  they  are  introduced 
directly  into  the  wound  on  dirty  instruments  or  dressings  or  by  the 
hands  of  the  surgeon.  When  they  thus  gain  an  entrance  in  sufficient 
numbers  they  cause  suppuration  and  prevent  healing  by  first  intention. 
Wounds  which  have  been  greatly  bruised  either  by  injur}-  or  irritating 
antiseptic  agents  or  prolonged  manipulation  are  more  susceptible  to 
their  action  than  cleanly  cut  wounds.  The  same  is  true  of  wounds  the 
lips  of  which  are  in  a  state  of  tension. 

Bacteria  cannot  gain  an  entrance  directly  through  the  cutis  vera, 
but  may  find  their  way  through  the  numerous  minute  openings  of  the 
skin,  more  particularly  the  hair-follicles  and  the  sebaceous  glands,  and 
perhaps  also  the  sweat-ducts.  This  has  been  demonstrated  by  Garre, 
who  rubbed  a  large  quantity  of  an  aureus  culture  into  the  uninjured 
skin  of  his  left  arm  and  produced  a  carbuncle. 

The  bacteria  also  frequently  gain  an  entrance  through  minute 
wounds  in  the  skin,  and  many  severe  internal  suppurations  such  as 
osteomyelitis  trace  their  origin  to  infection  through  this  route.  A 
child  is  constantly  receiving  bruises,  and,  if  the  system  is  enfeebled, 
the  pyogenic  organisms  which  abound  in  dirty  clothing  may  be  inocu- 
lated into  these  openings. 

The  nates  of  oarsmen,  particularly  when  overtrained,  receiving  abrasions  from  friction, 
are  exposed  to  infection  from  the  clothing  saturated  with  the  products  of  cutaneous  excre- 
tion and  desquamation.  The  nasal  cavity  is  usually  free  from  bacteria,  but  the  pharynx 
and  the  mouth  contain  large  numbers  of  bacteria  of  a  great  many  varieties,  not  all  of  which, 
however,  are  pathogenic.  Pyogenic  organisms  are  frequent  in  the  pharynx,  and  the  pneu- 
mococcus  is  found  habitually  in  the  mouth. 

It  is  due  to  this  cause,  probably,  that  many  severe  operations,  espe- 
cially those  of  the  digestive  tract,  are  followed  by  pneumonia.  The 
toilet  of  the  mouth  is  now  becoming  recognized  as  a  part  of  the  prepa- 
ration of  a  patient  for  capital  operations.  The  tonsil  has  been  described 
as  a  "  physiological  wound,"  so  susceptible  is  it  to  infection.  Not  only 
tonsillitis,  but  probably  also  many  other  forms  of  internal  septic  proc- 
esses, receive  their  virus  through  this  gate  of  entrance.     The  cervical 

62 


SUPPURATION.  63 

lymph-glands  act  as  strainers  to  many  of  these  organisms,  and  more 
particularly  to  the  tubercle  bacillus. 

Many  pathogenic  organisms  find  their  way  into  the  intestinal  canal  with  food  and  drink, 
and  many  are  indigenous.  Under  favorable  circumstances  peritoneal  infection  ma)-  occur 
directly  through  the  intestinal  walls.  Tuberculous  adenitis  of  the  mesenteric  glands,  tabes 
mesenterica,  owes  its  origin  to  infection  from  this  source.  Some  of  the  most  grave  infections 
are  due  to  a  sepsis  intestinalis. 

From  whatever  source  they  are  derived,  the  bacteria  exert  their 
pathogenic  action  only  when  concentrated  at  any  given  point  in  suf- 
ficient numbers.  Capillary  systems  in  which  the  current  is  not  too 
active  favor  these  conditions,  and  it  is  usually  at  some  such  point,  as, 
for  instance,  a  capillary  loop  of  the  kidney,  or  one  of  the  vessels  of  the 
rich  capillary  network  of  the  epiphyseal  line  in  long  bones,  that  a  clus- 
ter or  plug  of  organisms  becomes  arrested.  As  the  organisms  multi- 
pi)-,  the  material  (bacterial  proteid)  given  off  by  them  exerts  a  poison- 
ous action  on  the  adjacent  tissue,  resulting  in  a  coagulation  necrosis 
or  death  of  the  part  with  which  the  virus  comes  in  contact.  The  irri- 
tating substances  exert  a  chemotactic  action  also  upon  the  wandering 
cells  and  leukocytes  which  presently  begin  to  appear  in  large  numbers, 
often  in  columns,  and  surround  the  mass  of  dead  tissue.  If  an  abscess 
is  examined  at  this  early  stage,  there  is  found  in  the  center  of  it  a 
cluster  of  micrococci  embedded  in  a  mass  of  necrosed  tissue,  the  out- 
lines of  which  may  still  be  discerned,  but  which  forms  a  more  or  less 
transparent  zone  around  them  (Fig.  19).     Surrounding  this  mass  of 


■ 


■ 


Fig.  19. — Metastatic  abscess  of  kidney  :  plugs  of  micrococci  in  central  necrosis,  with  surround- 
ing cell-infiltration  (oc.  3,  obj.  A)  (Warren). 

broken-down  tissue  is  a  wall  of  leukocytes.  As  the  abscess  grows  in 
size,  the  leukocytes  wander  into  the  necrosed  area  and  mingle  with  the 
micrococci.  Many  of  the  foremost  ranks  of  the  wall  of  leukocytes  are 
separated  from  their  neighbors  by  the  liquefaction  of  the  intercellular 
substance,  which  liquefaction  is  caused  by  the  peptonizing  action  of 
the  bacteria.  To  this  fluid  is  added  that  which  escapes  from  the  adja- 
cent blood-vessels  with  the  exudation.     In  this  way  the  amount  of 


64  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

fluid  material  is  increased.  At  this  stage  the  central  area  is  occupied 
with  a  semi-fluid  mass  containing  fragments  of  broken-down  tissue, 
leukocytes,  and  bacteria.  Enclosing  this  is  the  zone  of  cell-infiltration 
which  forms  the  wall  of  the  abscess  and  serves  as  a  barrier  against 
further  progress  of  the  infection.  The  inner  layer  of  this  tissue  con- 
tains bacteria  in  varying  quantities,  and  when  the  abscess  is  "  spread- 
ing," the  bacteria  are  found  near  the  outer  margin  of  the  tissue  which 
then  is  breaking  down  before  the  onward  growth  of  these  organisms. 

The  tension  of  the  tissues  over  some  point  in  the  abscess  cavity 
becomes  very  great  from  the  presence  of  the  enclosed  fluid,  the  parts 
here  are  stretched  and  further  softened  by  necrotic  action  ;  the  abscess 
"  points,"  and  finally  breaks,  allowing  the  contents  (which  are  now  a 
cream-like  fluid)  to  be  discharged.     These  contents  are  known  as  pus. 

An  abscess  may  be  defined  as  a  circumscribed  collection  of  pus. 
The  tissue  lining  the  walls  of  the  abscess  cavity  is  called  granulation- 
tissue.  This  tissue  consists  chiefly  of  small  round  cells  with  very  little 
intercellular  substance,  and  is  very  rich  in  capillary  blood-vessels. 
There  are  numerous  polynucleated  cells  near  the  surface  which  are 
breaking  down,  and  about  to  be  thrown  off  from  the  surface  as  pus- 
corpuscles.     There  are  also  a  number  of  leukocytes  with  single  nuclei, 


FIG.  20. — Portion  of  wall  of  lung-abscess,  natural  injection  (oc.  3,  obj.  A)  (Warren). 

and  of  larger  cells,  each  with  a  large  oval,  bright  nucleus,  which  are 
called  epithelioid  cells.  The  smaller  cells  are  broken  down  and  ab- 
sorbed, but  the  larger  cells  are  active  agents  in  the  process  of  repair 
during  the  healing  of  the  abscess. 

The  wall  of  the  cavity  is  at  first  lined  with  pus  and  shreds  of 
broken-down  tissue,  but  when  this  has  been  discharged  and  the  inner 
surface  "  cleans  off,"  the  lining  membrane  is  found  to  consist  of  a 
bright-red  and  highly  vascular  tissue,  the  surface  of  which  is  dotted 


SUPPURA  TION. 


65 


with  little  nodules.  These  are  known  as  "granulations"  (Fig.  20). 
By  this  time  the  cavity  has  shrunk  greatly.  The  walls  approach  one 
another  and  the  granulations  grow  up  from  below,  and  finally  only  a 
superficial  granulating  surface  is  left,  which  slowly  contracts  and  is 
finally  covered   by  epithelium. 

Symptoms  of  Suppuration. — The  formation  of  an  abscess  is 
accompanied  by  a  great  amount  of  swelling  of  the  surrounding  tissues, 
which  are  made  tense  and  brawny  by  the  exudation  with  which  they 
are  infiltrated.  A  bright-red  blush  extends  even  to  the  surrounding 
tissues.  As  the  tension  increases,  the  pain  becomes  acute,  and  is  of  a 
throbbing  or  a  boring  character.  There  is  also  considerable  constitu- 
tional disturbance.  The  advent  of  suppuration  is  usually  ushered  in 
by  a  chill  or  a  sudden  rise  of  temperature,  which  remains  high  or 
increases  until  the  pus  is  discharged. 

As  pus  approaches  the  surface,  the  tissues  near  the  center  of  the 
inflamed  mass  become  softer,  and  on  pressure  with  the  fingers  are  said 
to  fluctuate.  Near  the  center  of  this  soft  area  a  white  spot  appears. 
At  this  period  the  pain  is  most  acute  and  is  lancinating  in  character, 
and  the  febrile  disturbance  is  at  its  height. 

When  the  abscess  breaks  and  there  is  a  free  discharge  of  pus,  both 
local  and  constitutional  symptoms  subside.  The  blush  fades,  the  skin 
becomes  wrinkled,  and  the  pain  disappears.  Should  the  temperature 
remain  high,  "  burrowing  "  of  pus  is  to  be  feared,  and  the  open  cavity 
should  be  inspected  carefully  to  see  if  the  pus  has  a  free  vent.  During 
the  healing  process  and  for  some  time  after  the  wound  has  healed,  the 
tissues  that  were  involved  have  a  deeper  tinge  of  color  than  the  sur- 
rounding normal  integuments. 

Pus  is  a  yellowish-white  substance  of  the  consistency  of  cream,  and 
in  its  "  normal  "  condition  is  odorless  and  has  an  alkaline  or  faintly 
acid  reaction.  When  allowed  to  stand,  a  sediment  is  formed  which, 
under  the  microscope,  is  found  to  consist  almost  entirely  of  pits-corpus- 
cles (Fig.  21).  There  are  also  found  some  broken-down  tissue-cells, 
fragments  of  fibrous  tissue,  and 
various  forms  of  bacteria,  prin- 
cipally the  pyogenic  cocci.  There 
is  also  a  certain  amount  of  gran- 
ular debris,  the  remains  of  broken- 
down  cells  and  blood-corpuscles. 
The  fluid  is  known  as  liquor  puris 
or  pus-serum.  It  is  a  pale  yel- 
lowish fluid,  which  differs  some- 
what from  blood-serum  in  con- 
taining the  products  of  the  de- 
composition of  the  tissues  during 
the  suppurative  process,  such  as 
leucin  and  tyrosin.  It  also  con- 
tains peptone.  The  principal 
source  of  the  pus-cells  is  the 
blood  from  which  the  leukocytes 
migrate  to  the  focus  of  suppuration.  When  treated  with  acetic  acid 
and  the  various  staining  methods,  these  corpuscles  are  found  to  contain 
5 


FIG.  21. — Pus-cells  treated  with  acetic  acid, 
and  crenated  red  blood-corpuscles  (oc.  4,  obj. 
D)  (Warren). 


66  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

several  nuclei.  This  polynuclear  condition  is  not  a  sign  of  cell-activity, 
but  one  of  degeneration.  Many  of  the  cells,  however,  when  examined 
in  the  fresh  state,  have  ameboid  movements.  The  tissue-cells  are  rep- 
resented to  a  certain  extent  among  the  pus-corpuscles,  but  their  number 
is  quite  limited.  Bacteria  are  rarely  seen  in  the  interior  of  pus-cells, 
but  they  are  usually  found  between  them  floating  in  the  pus-serum. 
Pus  may  appear  very  differently  according  to  the  character  of  the  in- 
fection and  the  activity  of  bacterial  growth. 

The  thick  creamy  pus  which  forms  when  an  abscess  has  "ripened" 
(a  process  which  lasts  two  or  three  days),  is  known  as  healthy  or  laud- 
able pus.     It  has  comparatively  few  bacteria  in  it. 

Ichor  is  a  name  given  to  pus  in  a  state  of  decomposition.  The  pus- 
cells  are  few  in  number  and  bacterial  growth  is  active,  the  bacteria  of 
decomposition  replacing  those  of  suppuration. 

Sanies  is  pus  usually  mixed  with  blood,  and  is  also  in  a  state  of 
decomposition.  These  forms  of  pus  are  very  irritating,  and  have  either 
a  strongly  acid  or  an  ammoniacal  reaction. 

Cultures  taken  from  any  of  the  above-named  varieties  of  pus  often 
prove  to  be  sterile.  This  is  due  to  the  fact  that  the  organisms  have 
died.  Sterile  cultures  are  taken  from  abscesses  of  long  standing,  such 
as  are  seen  in  cases  of  pyosalpinx,  also  in  the  pus  from  an  old  empyema, 
even  when  foul  smelling.  The  fetid  pus  from  an  ischiorectal  abscess  is 
generally  due  to  the  growth  of  the  Bacillus  pyogenes  fcetidus.  The 
thin,  purulent  fluid  taken  from  the  peritoneal  cavity  oozing  from  a 
fresh  appendicial  abscess  contains  an  active  growth  of  the  Bacillus  coli 
communis. 

Blue  pus  is  caused  by  the  presence  of  the  Bacillus  pyocyaneus.  It 
has  no  special  pathological  significance. 

Orange-colored  pits  is  found  often  in  rapidly  spreading  forms  of 
phlegmonous  inflammation.  It  is  due  to  a  deposit  of  hematoidin  crystals 
on  the  granulating  surfaces  caused  by  the  presence  of  extravasated 
red  blood-corpuscles  in  the  exudation.     It  is  rarely  seen. 

Red  pus  is  also  a  rare  occurrence.  It  is  due  to  the  presence  of  a 
bacillus  about  one-third  the  diameter  of  a  red  blood-corpuscle.  The 
cultures  in  blood-serum  have  a  bright-red  color  which  later  changes  to 
violet.  The  red  pus  is  best  seen  on  white  dressings  when  first  removed. 
It  can  readily  be  distinguished  from  blood  with  a  little  practice.  If 
allowed  to  dry  upon  the  dressings,  it  does  not  change  color,  whereas 
blood  soon  assumes  a  dirty-brown  color. 

Tuberculous  pus  is  not  considered  true  pus  by  many  authorities.  It 
is  a  pale  chalky  fluid,  with  inspissated  cheesy  masses  and  clots  of  fibrin 
floating  in  it.  It  contains  but  a  few  pus-corpuscles  and  no  pyogenic 
cocci.  The  sediment  consists  of  the  fragments  of  broken-down  tissue, 
and  of  a  few  tubercle  bacilli.  It  is  often  difficult  to  find  the  bacilli,  and 
even  to  obtain  cultures  of  them,  but  inoculations  in  guinea-pigs  pro- 
duce a  miliary  tuberculosis.  It  is  probable  that  these  tubercles  are 
developed  from  sepsis,  although  the  existence  of  spores  in  tubercle 
bacilli  has  not  yet  been  demonstrated. 

The  Microscopical  Examination  of  Pus. — Spread  the  pus  in  very  thin  streaks 
over  the  surface  of  a  cover-glass  by  means  of  a  platinum  wire,  and  dry  it  either  in  the  air  or 
over  a  flame.      Then,  holding  the  preparation  with  cover-glass  forceps,  pass  it  rapidly  three 


ABSCESS.  67 

times  through  the  flame,  to  "  fix  "  it.      The  preparation  is  now  ready  to   be   stained  by  any 
of  the  various  methods  which  have  been  devised. 

For  most  purposes  staining  with  a  solution  of  methylene  blue  is  sufficient,  for  this  dye 
stains  sharply  not  only  the  nuclei  of  pus-cells,  but  most  bacteria  as  well.  This  solution 
consists  of  a  mixture  of  30  c.c.  of  a  saturated  alcoholic  solution  of  methylene  blue  and  100 
c.c.  of  a  I  :  10,000  solution  of  potassium  hydroxid. 


Fig.   22. — Sterilized   test-tube   and   swab    for   collecting   pus   and    fluids    for  bacteriological 

examination  (Warren). 

In  staining,  the  cover-glass  preparation,  held  in  the  grasp  of  cover-glass  forceps,  is  cov- 
ered with  the  staining  solution  and  gently  heated  for  a  few  seconds  over  a  flame.  It  is  then 
washed  in  water,  dried  thoroughly  and  mounted,  stained  surface  down,  in  balsam  on  a  slide. 
If  desired,  the  preparation  may  be  examined  without  mounting  in  balsam,  by  simply  plac- 
ing it  on  a  slide,  charged  surface  down,  and  drying  off  the  surface  of  the  cover-glass.  If 
this  procedure  is  adopted,  it  is  accessary  that  there  should  be  a  layer  of  water  between  the 
cover-glass  and  the  slide,  in  order  that  good  optical  definition  may  be  obtained. 

Pus  may  also  be  examined  unstained  and  in  "  fresh"  condition  by  placing  a  drop  of  it 
upon  a  slide  and  then  upon  this  a  cover-glass. 

If  desired,  a  drop  of  acetic  acid  may  be  run  under  the  cover-glass  to  bring  out  the  out- 
lines of  nuclei. 

ABSCESS. 

Abscess  is  divided  into  two  varieties,  the  acute  and  the  cold  abscess. 
The  latter  is  due  to  the  presence  of  the  tubercle  bacillus,  and  will  be 
considered  in  the  chapter  on  Tuberculosis. 

Acute  abscesses  may  be  divided  into  several  general  classes  accord- 
ing to  their  situation.  They  may  be  superficial,  such  as  boils,  subfascial, 
subperiosteal,  or  in  the  bone.  Still  more  deep-seated  are  those  con- 
nected with  the  internal  organs,  which  may  be  designated  visceral. 

Abscesses  of  the  skin  are  among  the  most  common  forms. 
Infection  of  the  skin  may  be  most  superficial,  or  it  may  penetrate  into 
the  subcutaneous  tissues,  and  may  give  rise  to  pustules,  boils,  or  car- 
buncles. 

When  the  micro-organisms  penetrate  the  hair-follicles  as  far  as  the 
sebaceous  glands  and  form  a  minute  focus  of  suppuration,  there  results 
a  pustule,  which  may  vary  in  size  according  to  its  seat  in  the  upper 
part  of  the  follicle,  in  the  coil  of  a  sweat-gland,  or  in  the  large  seba- 
ceous glands. 

The  boil  or  furuncle  is  caused  by  an  invasion  of  bacteria  either 
through  the  hair-follicles  or  sudoriparous  glands  to  a  deeper  portion 
of  the  skin  or  to  the  subcutaneous  cellular  tissue.  The  active  growth 
of  the  organisms  is  sufficiently  extensive  in  this  case  to  produce  a 
coagulation  necrosis  of  appreciable  size  which  subsequently  forms  the 
"  core  "  of  the  boil.  The  part  most  frequently  destroyed  is  the  hair- 
follicle  with  its  accompanying  sebaceous  gland.  The  first  symptom  of 
a  boil  is  the  appearance  of  a  minute  pustule  situated  at  the  opening 
of  a  hair-follicle.  Its  presence  is  first  noticed  on  account  of  an  itching 
sensation  which  it  causes.  This  is  soon  followed  by  an  infiltration  of 
the  skin  which  finally  extends  to  subcutaneous  cellular  tissue.  A  crust 
forms  on  the  site  of  the  papule,  and  on  removing  this  a  small  quantity 


68  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

of  pus  escapes.  On  introducing  a  fine  probe,  it  is  found  to  enter  to  the 
depth  of  half  an  inch.  The  boil  continues  to  enlarge  for  a  day  or  two, 
and  the  opening  is  now  sharply  defined  and  circular,  and  is  sufficiently 
large  to  enable  the  pus  to  escape  freely.  Finally  pressure  extrudes  a  small 
slough  and  the  inflammation  begins  to  subside,  the  opening  contracts, 
and  the  minute  abscess  eventually  heals  by  granulation.  The  pain  is 
at  first  slight,  itching  being  the  most  prominent  sensation.  This  is  re- 
placed later  by  soreness  which  is  rarely  more  acute,  but  is  omnipresent, 
owing  to  the  superficial  and  exposed  situation  of  the  inflammatory 
focus.  During  the  period  of  greatest  tension  upon  the  skin  there  may 
be  severe  pain. 

Furunctllosis  is  a  term  applied  to  those  cases  in  which  the  patient 
is  afflicted  with  a  succession  of  boils.  Contagion  occurs  by  the  smear- 
ing of  the  discharge  over  the  adjacent  surfaces  and  also  by  the  inocula- 
tion of  dried  pus  by  the  finger-nails  of  the  patient  during  scratching  or 
other  manipulation.  In  this  condition  there  is  an  undue  susceptibility 
of  the  tissue  owing  to  some  disordered  condition  of  the  system. 

Carbuncle  is  a  suppurative  and  gangrenous  inflammation  of  the 
skin  and  the  subcutaneous  cellular  tissue,  which  begins,  like  furuncle, 
on  the  surface  of  the  skin  and  spreads  gradually  downward  and  later- 
ally into  the  subcutaneous  tissue.  In  its  earlier  stages  of  development 
the  infected  area  may  have  the  form  of  a  cone,  the  apex  being  the 
starting-point  in  a  hair-follicle,  sweat-duct,  or  minute  abrasion.  The 
organisms  most  frequently  found  in  carbuncular  pus  are  the  Staphylo- 
coccus pyogenes  aureus  and  albus.  A  state  of  general  debility  places 
the  tissues  in  a  condition  to  furnish  a  favorable  soil  for  the  growth  of 
bacteria.  Certain  constitutional  diseases,  such  as  diabetes,  seem  fre- 
quently to  be  accompanied  by  carbuncle.  The  disease  is  rarely  seen 
in  childhood.  It  is  most  frequently  observed  in  persons  over  forty 
years  of  age.  A  carbuncle  is  usually  situated  at  the  back  of  the  neck, 
although  carbuncular  inflammations  are  occasionally  seen  upon  the  face 
and  upon  other  portions  of  the  body.  The  spread  of  the  infection  after 
it  reaches  the  subcutaneous  tissue  is  horizontal  and,  later,  up  toward 
the  surface. 

The  subcutaneous  tissues  on  the  back  differ  anatomically  from  those  of  other  portions  of 
the  body  where  the  skin  is  thinner.  Here  the  skin  is  double  the  thickness  of  that  on  the 
inner  side  of  the  amis  and  the  abdomen.  This  integument  is  held  down  to  the  subjacent 
fascia  by  fibrous  bands  of  considerable  size.  Near  the  point  of  origin  of  these  bands  are 
the  columns  adiposas,  or  columns  of  adipose  tissue,  in  which  the  hair-follicles  of  the  lanugo 
hairs  take  their  origin.  Coils  of  sudoriparous  glands  are  also  found  suspended  in  this 
tissue. 

As  the  suppuration  spreads  deeply,  it  seeks  a  route  to  the  surface 
through  these  columnae  adiposse,  and  thus  gives  the  characteristic  ap- 
pearance of  a  carbuncle  (Fig.  23).  When  fully  developed,  a  carbuncle 
is  characterized  by  its  broad  flat  base  and  flattened  oval  surface  raised 
considerably  above  the  level  of  the  skin.  The  skin  is  reddened,  and 
perforated  at  several  points  with  holes  of  considerable  size,  from  which 
oozes  pus.  The  skin  is  extremely  tense  and  red,  and  the  infiltrated 
parts  have  a  density  unusual  in  ordinary  inflamed  tissue.  The  smaller 
openings  in  the  center  gradually  fuse  into  one  or  more  larger  openings, 
through  which  large  sloughs  of  subcutaneous  tissue  may  be  discerned 


ABSCESS. 


69 


(Fig.  24).  Carbuncles  may  vary  greatly  in  size,  some  of  them  being 
several  inches  in  diameter.  In  the  larger  varieties  full  development  is 
reached  about  the  end  of  the  second  week,  and  the  final  healing  of  the 
wound  after  the  sloughs  have  been  cast  off  may  not  be  reached  for 


Fig.  23. — Infiltration  of  columna  adiposa  and  subcutaneous  tissue  with  pus  in  carbuncle 
(Warren):  a,  lanugo  hair;  b,  pus  cells  infiltrating  the  columna  and  lymph-spaces  of  cutis 
vera  ;  c,  cells  of  sweat-glands  ;  d,  muscular  fibers. 

five  or  six  weeks  or  even  longer.  The  constitutional  condition  of  the 
patient  varies  greatly.  In  the  milder  cases  there  may  be  little  or  no 
fever,  but  large  carbuncles  are  usually  associated  with  considerable 
cachexia.     When  diabetes  exists  the  prognosis  is  most  unfavorable. 


FIG.   24.— Diagram  of  a  carbuncle    (Warren);    a,  normal   thick  skin  containing  columnag 

adiposfe;  b,  carbuncle. 

Carbuncle  of  the  lip  is  a  deep-seated  suppuration,  usually  of  the 
upper  lip,  involving  the  skin  and  subcutaneous  tissue.  It  is  accompanied 
by  profound  constitutional  disturbance,  and  in  many  cases  the  prog- 
nosis is  most  unfavorable.  This  is  due  to  the  involvement  of  the  rich 
venoiis  anastomoses  with  the  cerebral  sinuses.  Death  may  occur  as  a 
result  of  both  meningitis  and  pyemia.     In   one  case  observed  by  the 


70 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


writer  there  was  a  general  infection  by  the  Streptococcus  pyogenes  with 
pyemia. 

The  treatment  of  boils  and  carbuncles  is  mainly  antiseptic.  It 
consists  in  an  effort  to  reach  the  locality  of  the  growth  of  the  organ- 
isms and  arrest  its  further  progress.  A  boil  may  be  aborted  in  this 
way  if  the  treatment  is  applied  early.  If  the  pustule  can  be  seen 
within  twenty-four  hours  from  its  first  appearance,  it  can  usually  be 
destroyed  by  boring  with  a  sharpened  piece  of  wood  dipped  in  pure 
carbolic  acid.  In  a  further  advanced  boil  the  infected  area  should 'be 
laid  open  by  a  crucial  incision,  so  that  the  acid  can  be  thoroughly 
applied.  A  fully  developed  boil  should  be  freely  opened,  curetted, 
and  disinfected  with  carbolic  acid  or  peroxid  of  hydrogen.  An  anti- 
septic poultice  (page  72)  may  be  applied.  If  in  an  exposed  situation, 
the  boil  had  better  be  allowed  to  run  its  course  without  incision,  as 
scarring  is  thus  avoided. 

The  treatment  of  carbuncle  varies  according  to  the  gravity  of  the 
case.  In  diabetic  patients  careful  attention  should  be  given  to  the  con- 
stitutional treatment  and  diet  before  attempting  surgical  interference. 


Fig.  25. — Case  of  excised  carbuncle.     Wound  healed  in  three  weeks. 

A  rapidly  spreading  carbuncle  in  a  man  of  good  constitution  had  better 
be  excised.  Two  semi-elliptical  incisions  include  those  portions  of 
the  skin  riddled  with  pustule.  Flaps  of  skin  are  then  dissected  upward 
and  downward  until  healthy  tissue  has  been  reached,  and  the  whole 
infected  area  is  then  excised  in  one  mass.  The  wound  should  be  disin- 
fected in  the  most  thorough  manner  and  dressed  with  iodoform  gauze, 
outside  of  which  a  large  aseptic  absorbent  dressing  should  be  applied. 
Fever  and  local  inflammation  cease  promptly,  and  the  wound  soon 
begins  to  granulate.  It  heals  rapidly,  and  leaves  a  comparatively  small 
scar  (Fig.  25). 

Antisepsis  of  the  skin  of  the  infected  locality  should  be  enjoined 
upon  the  patient  for  some  time  after  the  healing  either  of  boils  or  car- 
buncle, as  the  tendency  to  recurrence  is  occasionally  very  obstinate. 


ABSCESS.  7 1 

This  can  be  accomplished  by  daily  ablutions  with  soap  and  water  and 
the  use  of  alcohol  externally.  The  patient  should  also  be  directed  to 
cleanse  the  hands  and  nails  thoroughly  each  time  after  dressing  the 
sore.  Frequent  changes  of  underclothing  should  also  be  made,  so  that 
all  possible  sources  of  infection  may  be  avoided.  Fowler's  solution  of 
arsenic  should  be  administered  internally. 

Subfascial  abscess  includes  those  forms  of  suppuration  found  in 
the  intermuscular  septa  or  beneath  the  fasciae  which  enclose  the  mus- 
cles. They  may  arise  from  a  blow  or  a  muscular  strain  or  as  the  result 
of  a  lymphatic  infection.  Suppurative  adenitis  is  a  frequent  source  of 
such  abscess  in  the  neck,  in  the  axilla,  and  in  the  fasciae.  An  inflamed 
bursa  may  also  be  the  source  of  such  abscesses. 

The  anatomical  arrangement  of  the  fascia*  and  the  spaces  which  they  enclose  often 
determines  the  route  these  abscesses  pursue.  In  the  neck,  for  instance,  is  found  the  deep 
cervical  abscess,  which  forms  in  the  upper  triangle  in  one  of  the  lymphatic  glands  situated 
near  the  angle  of  the  jaw.  This  abscess  burrows  downward,  sometimes  to  the  anterior 
mediastinum,  owing  to  its  inability  to  penetrate  the  deep  layer  of  the  cervical  fascia.  A 
subfascial  abscess  may  also  take  its  origin  from  an  inflammation  arising  in  an  adjacent 
organ,  as  the  kidney,  giving  rise  in  this  case  to  a  perinephritic  abscess.  Suppuration  may 
occur  as  the  result  of  a  strain  or  rupture  of  some  internal  muscle,  such  as  the  psoas  magnus. 

The  earliest  symptoms  of  such  deep  abscesses  are  chiefly  of  a  sub- 
jective nature.  At  first  a  slight  local  edema  without  swelling  or  red- 
ness may  be  seen.  In  a  few  days  there  is  evidence  of  deep-seated 
infiltration,  and  the  part  becomes  tender  on  pressure.  As  the  inflam- 
mation approaches  the  surface,  all  the  symptoms  become  more  marked. 
At  this  time  the  skin  is  tense  and  red,  and  the  subjacent  tissues  are 
swollen  and  infiltrated.  There  is  earl}'  fever,  and  an  examination  of 
the  blood  will  show  a  marked  leukocytosis. 

The  treatment  of  these  abscesses,  often  large  and  deep-seated,  is 
of  much  importance.  Once  the  diagnosis  has  been  made,  they  should 
be  opened  in  order  to  prevent  extension  of  the  suppuration  and  unnec- 
essary destruction  of  tissue  and  perhaps  fatal  systemic  infection.  Such 
abscesses  should  always  be  opened  with  strict  antiseptic  precautions, 
firstly  because  their  contents  may  prove  to  be  sterile,  and  secondly 
because  a  mixed  infection  might  add  to  the  virulence  of  the  inflam- 
matory process.  An  incision  should  be  made  large  enough  to  enable 
the  operator  to  reach  all  parts  of  the  interior  of  the  abscess-cavity. 
The  fluid  contents  having  been  thoroughly  evacuated  by  pressure, 
douching,  or  sponging,  the  walls  should  be  thoroughly  curetted  in 
order  to  remove  the  abscess-wall  or  that  portion  of  it,  at  least,  which 
contains  the  pyogenic  organism.  The  remaining  cavity  should  then 
be  disinfected  thoroughly  with  carbolic  acid  i  :  ioo,  corrosive  subli- 
mate i  :  iooo,  or  peroxid  of  hydrogen,  and  packed  with  iodoform  gauze. 
Occasionally  an  abscess-wall  may  be  so  accessible  as  to  be  reached 
and  dissected  out  by  the  knife.  Under  these  circumstances  it  would 
be  possible  to  obtain  healing  by  first  intention.  It  is  better  in  doubtful 
cases  to  pack  with  gauze  and  bring  the  walls  together  a  day  or  two 
later  by  tying  the  provisional  sutures. 

If  it  is  not  possible  to  disinfect  the  cavity  thoroughly,  then  drain- 
age in  some  form  should  be  used.  Rubber  drains  are  most  useful  for 
this  purpose,  and  can  be  packed  in  place  with  gauze.  If  it  be  desirable 
to  keep  the  edges   of  the  wound  moist,  large  antiseptic  poultices  of 


J 2  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

moist  gauze  may  be  used.  They  should  be  changed  every  two  or 
three  hours  when  the  discharge  is  free  and  foul.  Corrosive  sublimate 
when  used  in  a  poultice  should  not  be  strong,  I  :  10,000  being  suffi- 
cient. Sulpho-naphthol  1  :  500  or  creolin  may  be  employed  as  useful 
substitutes.  In  deep-seated  abscess,  involving  internal  organs,  such  as 
perinephritic  abscess,  the  operation  required  is  one  of  major  importance. 

Panaritium  or  felon  is  another  example  of  subfascial  abscess. 
Its  origin  varies,  for  it  may  begin  in  the  skin,  in  the  subcutaneous 
tissue,  in  the  tendons,  or  in  the  periosteum.  The  infection  takes 
place  through  some  skin-abrasion,  callus,  blister,  or  punctured  wound. 
Cooks,  butchers,  and  dissectors  are  liable  to  these  infections,  their 
hands  coming  in  contact  with  putrescible  substances.  The  anatomical 
arrangement  of  the  connective-tissue  felon  on  the  palmar  surface  of 
the  hand  and  fingers  is  such  that  it  runs  perpendicularly  inward  to  the 
palmar  fascia  or  to  the  sheaths  of  the  tendons,  and  the  infective  mate- 
rial is  for  this  reason  readily  directed  to  the  deeper  parts.  The  felon 
is  usually  found  at  the  end  of  the  fingers.  It  begins  with  an  intense 
throbbing  pain  and  gradually  increasing  swelling.  There  is  more  or 
less  fever  and  great  suffering  from  the  throbbing  character  of  the  pain. 
The  pus  is  confined  either  beneath  the  periosteum  or  the  tendon  or 
fascia,  and  if  not  evacuated  may  spread  and  break  into  the  tendon 
sheaths,  and  thence  extend  into  the  palm  of  the  hand.  This  extension 
occurs  most  readily  in  the  sheaths  of  the  tendons  of  the  thumb  and 
little  finger,  which  are  continued  into  the  palm  of  the  hand  and  beneath 
the  annular  ligament. 

Abscesses  which  form  under  the  palmar  fascia  are  known  as  palmar 
abscesses.  The  infection  may  be  transmitted  from  the  fingers,  as  above 
stated,  or  it  may  occur  through  bruises,  wounds,  or  blisters  in  the  skin 
of  the  palm  of  the  hand.  Like  the  felon,  this  abscess  is  liable  to  spread 
rapidly,  and  if  it  is  neglected,  pus  may  in  a  day  or  two  be  found  above 
the  annular  ligament,  and  may  even  dissect  apart  the  deeper  structures 
of  the  forearm.  When  a  palmar  abscess  reaches  its  stage  of  full  de- 
velopment, the  whole  hand  is  involved,  the  integuments  are  greatly 
swollen,  the  natural  furrows  of  the  hand  disappear,  the  fingers  are 
flexed,  and  the  hand  assumes  a  claw-like  aspect. 

The  treatment  of  abscess  of  the  fingers  and  the  palm  of  the  hand 
should  be  most  prompt,  as  delay  may  permit  disorganization  not  only 
of  the  soft  parts  but  even  of  the  bones  and  joints  of  the  hand.  In 
case  of  felon,  the  knife  should  be  carried  down  to  the  bone  and  cut 
clean  to  the  end  of  the  finger-pulp.  In  making  incisions  into  the  palm, 
care  should  be  taken  to  avoid  the  vessels  of  the  palmar  arch.  Brooks's 
method  of  making  incisions  along  the  folds  of  the  palm  (Fig.  26),  turn- 
ing back  a  large  flap,  and  curetting  the  subjacent  abscess  is  an  improve- 
ment on  the  older  methods.  By  carefully  determining  the  seat  of  the 
pus  the  knife  may  be  used  without  fear,  and  when  the  pus-cavity  once 
has  been  opened,  its  various  ramifications  should  be  followed  to  their 
farthest  point  of  extension.  After  a  prolonged  bath  in  some  warm 
antiseptic  solution  the  hand  should  be  placed  in  a  large  antiseptic 
poultice  reaching  nearly  to  the  elbow.  The  arm  should  either  be 
placed  upon  a  splint,  or  if  the  case  is  serious  the  patient  should  be 
placed  in  bed  and  the  arm  allowed  to  lie  upon  a  pillow,  the  hand 


ABSCESS. 


71 


being  very  slightly  elevated.  Serious  contraction  of  the  finger  may 
occur,  due  to  sloughing  of  the  tendons  or  the  formation  of  cicatricial 
bands. 

Phlegmonous  inflammation  is  a  term  given  to  the  spreading 
forms  of  suppuration,  such  as  are  usually  produced  by  the  invasion  of 
the  streptococci.  In  these  cases  all  the  signs  of  acute  inflammation 
are  present  and  the  area  involved  is  extensive.  The  connective-tissue 
spaces  and  the  lymphatic  vessels   are  the  routes  through   which  the 


FIG.  26. — Brooks's  incision. 


virus  spreads.  The  streptococci  do  not  cause  suppuration  at  first,  but 
as  they  grow  they  exert  a  widespread  poisonous  influence  upon  the 
tissue.  If  an  incision  is  made  into  the  part  during  the  early  stage  of 
the  process,  there  is  set  free  a  more  or  less  clear  yellowish  fluid  which 
may  contain  a  few  pus-cells  or  flakes  of  fibrin.  Sloughing  begins 
early,  and  gradually  suppuration  is  established.  The  skin  is  freely 
loosened  from  the  fascia  by  the  death  of  the  intervening  structures, 
and  the  muscles  are  often  dissected  apart.  Such  inflammations  are 
often  the  sequel  of  infection  starting  as  a  felon  or  palmar  abscess. 
Frequently,  however,  the  virus  spreads  far  too  rapidly  for  suppuration 
to  become  established  at  these  points,  and  the  whole  arm  quickly  be- 
comes involved.  The  skin  is  hard  and  brawny  at  points,  and  covered 
here  and  there  with  bullae.  The  whole  limb  is  edematous.  In  some 
of  the  worst  forms  the  subcutaneous  tissue  becomes  emphysematous, 
due  to  the  presence  of  gas  given  off  by  the  gas-producing  bacillus  (Ba- 
cillus aerogenes  capsulatus  of  Welch).  Such  a  type  approaches  that 
form  of  septic  inflammation  known  as  malignant  edema,  due  to  infection 
with  the  bacillus  of  that  name.  The  occurrence  of  true  malignant 
edema  in  human  beings  is  regarded  by  Welch  as  an  unsettled  question. 

The  constitutional  disturbance  in  phlegmonous  inflammation  is  usu- 
ally profound,  and  may  develop  into  true  septicemia  if  the  streptococci 
gain  an  entrance  into  the  system  in  sufficient  numbers. 

A  good  example  of  phlegmonous  inflammation  is  seen  in  a  case  of 
compound  fracture  of  the  leg  which  has  become  septic.  In  such  a 
case  the  soft  parts  extending  from  the  ankle  to  the  knee  may  become 
involved  in  the  sepsis.  The  most  severe  type  of  this  inflammation  is 
phlegmonous  erysipelas. 

Pus  frequently  accumulates  in. large  quantities  in  the  previsceral  or 
postvisceral  spaces  of  the  neck  (cervical  abscess),  in  the  subdiaphrag- 
matic region,  around  the  kidney  (perinephritic  abscess),  the  liver,  the 


74  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

gall-bladder,  the  pancreas,  the  appendix,  and  the  uterine  adnexa.  Ab- 
scesses in  these  regions  are  of  special  interest  to  the  surgeon,  and  are 
described  in  their  appropriate  places. 

Diagnosis — The  symptoms  of  abscess  already  enumerated  suffice 
to  make  the  diagnosis  of  abscess  easy  in  the  great  majority  of  cases. 
Abscess  has,  however,  been  mistaken  for  a  great  variety  of  diseases. 
One  of  the  most  serious  errors,  and  one  which  has  frequently  been 
made,  is  to  mistake  aneurysm  for  abscess.  The  gush  of  arterial  blood 
which  follows  plunging  the  knife  into  such  a  swelling  leaves  no  further 
doubt  as  to  the  diagnosis.  Various  tumors,  such  as  sarcoma  or  fatty 
tumor,  may  be  mistaken  for  abscess. 

An  abscess  burrows  in  the  direction  of  least  resistance,  but  its  spread  is  not  due  to  press- 
ure alone,  but  to  the  infection  produced  by  the  bacteria.  Dense  fascia;  are,  however, 
usually  sufficiently  strong  to  prevent  infection  through  them  except  when  in  contact  with  the 
most  virulent  poisons.  It  is  not  good  surgery  to  count  upon  the  absorption  of  pus,  for  only 
verv  small  quantities  of  it  may  disappear  in  this  way.  Minute  or  miliary  abscesses  may 
disappear  entirely  by  absorption,  but  a  collection  of  pus  sufficiently  large  to  be  recognized 
clinically  is  a  focus  of  infection  and  a  source  of  danger  even  after  the  death  of  its  bacteria. 
Many  abscesses  which  have  been  supposed  to  be  absorbed  break  into  the  intestinal  canal. 
Appendiceal  abscesses  are  sometime-  cured  in  this  way. 

Treatment. — In  the  spreading  forms  of  inflammation  the  most 
prompt  intervention  on  the  part  of  the  surgeon  is  demanded.  The 
indications  are  to  reach  the  micro-organisms  at  all  points  where  they 
are  growing  actively  in  the  tissues  and  to  attack  them  with  all  the  re- 
sources of  antiseptic  methods.  Small  incisions  may  only  aggravate 
the  mischief  by  introducing  new  organisms.  Free  incisions  therefore 
are  indicated,  and  pus  should  be  followed  relentlessly  to  the  farthest 
point  of  the  suppurating  tissue.  When  the  area  involved  is  very  ex- 
tensive, it  may  be  preferable  to  make  multiple  incisions,  so  arranged 
that  drainage  may  satisfactorily  be  obtained  and  that  the  scar  may  be 
so  situated  as  not  to  interfere  with  the  function  of  the  part.  All 
sloughing  tissue  should  be  excised  or  scraped  away,  all  pus-cavities 
curetted,  and  all  exposed  surfaces  disinfected  by  free  douching  with 
antiseptic  washes.  Large  antiseptic  poultices  (p.  72)  are  the  best  form 
of  dressings,  as  they  favor  a  flow  of  serum  from  the  part,  and  thus  aid 
Nature  in  an  attempt  to  wash  away  the  virus.  Frequent  antiseptic 
baths  also  are  useful  for  this  purpose,  the  limb  being  allowed  to  remain 
for  an  hour  at  a  time  in  some  mild  antiseptic  fluid. 

The  internal  treatment  consists  in  the  free  use  of  alcoholic  stimu- 
lants. Strychnin  and  digitalis  ma}'  be  administered  when  the  pulse  in- 
dicates a  feeble  action  of  the  heart.  The  patient  should  be  kept  in  bed, 
and  the  limb  placed  in  a  comfortable  position  on  a  pillow.  Opium  may 
be  given  to  relieve  pain  and  to  ensure  rest. 

ULCER. 

An  ulcer  is  a  solution  in  continuity  of  the  skin  or  the  mucous  mem- 
brane which  shows  no  tendency  to  heal.  The  term  implies  that  the 
wound  or  granulating  surface  is  stationary  or  enlarging,  and  that  it  has 
developed  by  a  death  of  the  part  piecemeal.  It  owes  its  existence  to 
an  excess  in  action  of  the  retrograde  changes  over  those  of  repair. 
An  open  granulating  wound  is  not  an  ulcer,  but  it  may  become  one  if 


ULCER.  75 

the  granulations  begin  to  break  down  and  the  edges  begin  to  melt 
away.  A  large  granulating  wound  that  comes  to  a  standstill  owing  to 
the  inability  of  the  parts  to  cover  so  extensive  a  surface  is  called  an 
ulcer.  An  example  is  the  unhealed  end  of  an  amputation  stump.  Ulcers 
may  be  classified  according  to  their  mode  of  origin.  A  large  number 
of  ulcers  result  from  infection  producing  granulation-tissue  which  is  of 
low  vitality  and  easily  breaks  down.  The  diseases  which  most  fre- 
quently give  rise  to  ulceration  are  syphilis,  tubercle,  leprosy,  glanders, 
and  cancer. 

Ulceration  may  be  produced  by  disturbance  in  the  circulation  or  in 
the  nerve-supply.  Obliterative  changes  in  the  arterial  system  give  rise 
to  local  anemias  which  are  incompatible  with  the  life  of  the  part,  and 
thus  cause  ulceration.  Examples  of  such  changes  may  be  found  occa- 
sional!}' in  the  stomach  and  duodenum.  Passive  hyperemia  gives  rise 
to  stagnation,  softening,  and  degeneration,  and  pressure  may  cause 
stasis  and  necrosis.  Varicose  ulcers  and  decubitus  are  clinical  exam- 
ples of  such  conditions.  Disturbance  in  the  nerve-supply  gives  rise  to 
a  long  train  of  trophic  disturbances,  among  which  is  ulcer.  Local 
friction  may  cause  abrasions  which  develop  into  ulcers. 

The  surface  of  an  ulcer  is  usually  covered  with  a  layer  of  more  or 
less  broken-down  tissue  minszled  with  exudation.     It  may  be  in  a  state 


Fig.  27. — Chronic  ulcer  of  the  leg  (Warren). 

of  coagulation  necrosis  and  form  a  rind  which  covers  the  granulation- 
tissue  below  it.  In  a  section  of  an  ulcer  this  layer  of  granulation-tissue 
is  about  the  thickness  of  the  adjacent  cutis.  The  cells  of  which  it  is 
composed  are  largely  polynucleated  leukocytes  and  epithelioid  cells 
with  comparatively  little  intercellular  substance.  This  layer  is  more  or 
less  defined  owing  to  the  crowding  together  of  the  round-cell  elements 
which  characterize  it.  Beneath  this  layer  a  more  transparent  tissue  is 
seen  containing  a  larger  quantity  of  intercellular  substance   composed 


j6  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

of  pale  transparent  fibers  and  a  number  of  fusiform  cells.  Deeper  still 
the  tissues  become  more  fibrous,  partaking"  more  of  the  character  of 
cicatricial  tissue.  From  this  layer  blood-vessels  are  given  off  which 
run  more  or  less  vertically  upward  and  lose  themselves  in  a  capillary 
network  near  the  surface  of  the  ulcer.  The  base  of  the  ulcer  consists, 
as  will  be  seen  from  this  description,  of  two  principal  layers,  a  soft 
granulating  surface  which  can  easily  be  scraped  away,  and  a  denser 
tissue  beneath  it  which  remains  after  curetting.  This  appears  to  the 
naked  eye  as  a  dense  whitish  layer  bleeding  at  numerous  points.  It 
serves  as  a  sort  of  fascia  separating  the  morbid  tissue  from  the  sur- 
rounding healthy  parts  (Fig.  27). 

The  edges  of  old  ulcers  are  raised  somewhat  above  the  level  of  the 
base,  and  are  made  more  prominent  often  by  the  thickened  layers  of 
epidermal  tissue.  Such  ulcers  are  said  to  have  callous  edges,  and  the 
thickened  masses  of  epidermis  appear  to  be  an  ineffectual  effort  upon 
the  part  of  Nature  to  bridge  over  the  chasm.  Beneath  the  epidermis 
lies  the  papillary  layer.  The  papillae  are  more  or  less  elongated  and 
contain  a  rich  vascular  and  cellular  tissue  and  considerable  numbers 
of  granules  of  blood-pigment,  which  may  be  found  also  in  the  rete 
mucosum.  The  margins  of  the  ulcer  arc  sometimes  undermined.  This 
is  particularly  characteristic  of  tuberculous  ulcers.  Under  these  cir- 
cumstances its  edges  are  red  and  infiltrated,  and  often  have  a  bluish 
tinge. 

Varicose  Ulcer. — This  is  the  most  common  form  of  ulcer  seen  by 
the  surgeon.  It  is  found  upon  the  legs,  usually  at  the  junction  of  the 
middle  and  lower  thirds.     Its  origin  is  due  to  the  presence  of  varicose 


5x  "\ 

\  . 

7 

1 

1  \ '' 

1 

'  I '  I  in  \ 

; 

r 


%£0m 


FIG.  28. — Varicose  ulcer. 


veins  which  produce  a  stagnation  or  passive  congestion  of  the  capillary 
districts  involved.  The  surrounding  tissues  become  saturated  with  a 
thin  serum  which  oozes  through  the  walls  of  the  capillaries  and  small 
veins.  This  causes  edema  of  the  parts.  With  the  serum  there  is  an 
exudation  of  the  red  blood-corpuscles,  which  break  down  and  leave 
an  extensive  pigmentation  or  bronzing  of  the  parts.  The  nutrition  of 
the  tissues  is  enfeebled  and  the  edema  causes  a  softening  of  them.     A 


ulcer.  yj 

small  abrasion  occurs  finally  as  the  result  of  friction  or  some  slight 
trauma,  or  a  thrombosis  of  one  of  the  superficial  veins  produces  a 
slough,  and  the  minute  wound  thus  made  is  unable  to  heal.  Granula- 
tions form,  but  soon  break  down,  and  the  condition  of  ulceration  is 
established.  The  surrounding  parts  are  infiltrated  and  more  or  less 
infected  with  organisms,  and  are  further  softened  by  a  continuation  of 
the  inflammatory  process  now  developed.  These  ulcers  enlarge  grad- 
ually, and  at  times  an  acute  inflammation  may  supervene,  accompanied 
by  phlebitis  of  some  of  the  larger  veins.  Small  abscesses  form,  which 
break  but  do  not  heal.  When  the  local  inflammation  subsides,  the  orig- 
inal ulcer  has  become  greatly  enlarged.  These  varicose  ulcers  are 
occasionally  of  great  size  and  may  even  girdle  the  limb  (Fig.  28). 
When  neglected,  as  they  often  are  in  aged  or  infirm  people,  who  are 
unable  to  submit  to  treatment,  they  become  extremely  foul  and  are 
covered  with  a  rind  of  necrosed  and  decomposing  tissue. 

Decubitus  or  bed-sore  is  also  produced  by  obstruction  to  the 
circulation  by  direct  pressure  upon  the  part  affected.  Bed-sores  occur 
in  individuals  whose  circulation  is  enfeebled  by  disease  or  old  age,  and 
appear  beneath  the  bony  prominences  upon  the  posterior  aspects  of  the 
pelvis  and  inferior  extremities.  A  slough  is  formed  from  the  venous 
stasis,  and  around  this  ulceration  takes  place,  which  may  penetrate  to 
the  bone.  Such  bed-sores  are  liable  to  occur  at  parts  deprived  of  their 
nerve-supply,  as  after  injury  to  the  cord  in  fracture  of  the  spine.  They 
are  due  to  the  immobility  of  the  part  and  the  lack  of  pain,  and  also  to 
the  absence  of  innervation  by  the  trophic  nerves. 

Ulceration  may  also  be  caused  by  the  pressure  of  splints  {Splint- 
sores). 

A  characteristic  of  ulceration  from  absence  of  innervation  is  the 
so-called  mal perforans,  which  is  found  frequently  associated  with  loco- 
motor ataxia.  It  is  a  sharply-cut  circular  ulcer  developing  upon  the 
sole  of  the  foot,  is  deeply  excavated,  often  involving  a  joint,  and  is  sur- 
rounded by  an  overhanging  border  of  thickened  epidermis.  It  is 
probable  that  this  ulcer,  like  those  occurring  after  injuries  to  the  spinal 
cord,  is  principally  due  to  pressure.  Ulcers  are  named  frequently  ac- 
cording to  some  prominent  clinical  symptom  associated  with  them. 

An  inflamed  ulcer  is  one  which  develops  with  the  signs  of  more 
or  less  acute  inflammation,  such  as  occurs  often  in  the  life  history  of 
varicose  ulcers. 

Krethistic  ulcer  is  one  the  great  sensitiveness  of  which  persists. 
It  occurs  in  old  ulcers  of  bone  or  in  the  neighborhood  of  some  very 
sensitive  organ,  such  as  the  anus. 

Ulcers  may  be  fungous,  owing  to  the  presence  of  exuberant  and 
edematous  granulations.  Tuberculous  ulceration  often  presents  this 
appearance. 

Hemorrhagic  ulcers  are  seen  in  scurvy.  Torpid  ulcers  are  seen 
in  individuals  suffering  from  cachexia.  The  granulations  are  pale,  and 
the  secretion  is  thin  and  watery.  Tuberculosis  and  scurvy  are  diseases 
in  which  this  type  is  most  frequently  seen.  A  callous  ulcer  is  one 
which  has  remained  without  material  change  for  a  long  period  of  time. 
The  surface  is  dirty,  and  it  secretes  a  thin  mucopurulent  material. 
The  edges  are  raised  considerably  above   the   surface,  and  the  skin 


78  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

adjoining  is  indurated  and  immovable.  Old  varicose  ulcers  often 
present  this  type. 

Phagedenic  ulcers  are  those  which  spread  with  great  rapidity. 
The  edges  and  base  have  an  appearance  as  if  gnawed  by  a  rodent. 
Such  ulcerations  are  often  gangrenous  in  character.  These  appear- 
ances are  found  also  in  ulcers  which  have  been  treated  with  irritating 
applications.  A  chancre  occasionally  becomes  phagedenic,  and  when 
in  this  condition  is  an  unusually  obstinate  affection. 

The  Treatment  of  Ulcers. — Varicose  ulcers  are  best  treated  by 
rest  and  elevation  of  the  part.  In  the  majority  of  cases  they  will  heal 
under  these  circumstances.  This  method  of  treatment  is  hard  to  carry 
out,  as  these  ulcers  occur  in  that  class  of  patients  which  cannot  afford 
the  necessary  time.  When  it  is  necessary  to  treat  the  case  as  an 
ambulating  one,  the  hyperemia  may  be  relieved  by  bandaging  or  plas- 
ters. Rubber  bandages  are  useful  for  this  purpose,  as  they  can  be 
applied  even  by  the  most  ignorant,  and  can  be  kept  clean.  The  band- 
age should  be  allowed  to  remain  on  in  the  day-time  only.  Strapping 
with  strips  of  diachylon  or  rubber  plaster  is  a  good  substitute,  and  can 
be  used  in  the  milder  forms  of  ulceration,  the  plaster  being  changed 
every  few  days.  Very  foul  ulcers  must  be  treated  by  rest  in  bed  and 
the  local  use  of  antiseptic  poultices.  Such  poultices  can  be  made  by 
soaking  absorbent  cotton  or  gauze  in  solution  of  boric  acid  of  the 
strength  of  2  per  cent.,  or  in  phenyl  1  :  500.  Cleansing  washes  with 
peroxid  of  hydrogen  or  carbolic  acid  or  chlorinated  soda  favor  the 
restoration  of  a  healthy  granulating  surface.  If  it  is  desired  to  apply 
a  dry  dressing,  iodoform  or  aristol  may  be  dusted  over  the  surface. 
These  can  be  followed  by  the  use  of  pure  zinc  ointment,  which  forms 
a  protective  layer  not  easily  absorbed  by  dressings,  and  the  part  is  thus 
kept  from  scabbing. 

Painful  ulcers  are  not  amenable  to  any  one  form  of  dressing.  Poul- 
tices are  complained  of  bitterly  as  being  too  "  drawing."  Some  neu- 
tral ointment  or  one  mixed  with  cocain  hydrochlorate,  12  grs. :  5J,  often 
gives  relief. 

Indolent  ulcers  are  often  stimulated  by  the  application  of  balsam 
of  copaiba  or  Peru.  Tincture  of  myrrh,  sj :  3J  of  water,  has  a  tonic 
effect  upon  the  granulations.  Weak  solutions  of  tincture  of  iodin  have 
an  alterative  effect  upon  such  ulcers. 

Many  ulcers  owe  their  inability  to  heal  to  the  firm  adhesion  of  the 
surrounding  integuments  to  the  parts  below.  Much  benefit  has  been 
obtained  by  lateral  incisions  which  release  the  edges  and  permit  of 
cicatricial  contraction. 

Large  ulcers  are  best  treated  by  Thiersch's  method  of  skin-grafting. 
After  this  operation  upon  a  varicose  ulcer  the  patient  should  be  cau- 
tioned not  to  use  the  leg  too  soon,  as  the  cicatricial  tissue  formed  under 
the  grafts  readily  breaks  down.  A  rest  of  several  weeks  is  indispen- 
sable for  the  permanency  of  the  cure. 

FISTULA. 

A  fistula  may  be  defined  as  an  abnormal  opening  into  a  normal 
cavity  or  organ,  or  as  a  long  narrow  channel  indisposed  to  heal.     The 


FISTULA.  79 

latter  condition  is  usually  called  a  sinus.  The  term  "  fistula"  is  applied 
to  congenital  openings  or  defects  as  well  as  to  those  which  result  from 
abscess.  The  inflammatory  sinus  or  fistula  is  similar  in  character  to 
an  ulcer — that  is,  it  represents  a  wound  which  has  no  further  tendency 
to  heal. 

A  sinus  may  be  due  to  the  inability  of  the  parts  to  complete  cica- 
trization, owing  to  the  presence  of  a  foreign  body,  such  as  an  infected 
stitch  or  ligature.  The  locality  of  the  wound  may  be  such  that  un- 
avoidable movements  prevent  the  deeper  portions  of  the  wound  from 
healing.  A  fistula  is  generally  caused  by  the  escape  of  the  physiolog- 
ical secretions  or  excretions,  such  as  saliva,  urine,  or  feces.  When 
pus  has  burrowed  for  a  considerable  distance  beneath  the  skin,  and  a 
large  granulating  surface  has  been  established,  the  mere  shape  of  the 
cavity  is  in  itself  an  obstacle  to  cicatrization,  as  the  secretions  have  an 
opportunity  to  escape.  Such  sinuses  are  often  due  to  the  presence 
of  tuberculous  granulations. 

Treatment. — Superficial  sinuses  should  be  laid  open  freely  and 
their  areas  curetted.  A  careful  hunt  should  be  made  for  infected  liga- 
tures. These  can  often  be  secured  by  a  crochet  needle  or  a  fine  curet. 
Complete  extirpation  of  small  fistulas  is  sometimes  possible,  and  under 
these  circumstances  union  by  first  intention  can  be  obtained.  With 
careful  antiseptic  precautions  this  method  can  be  carried  out  in  cases 
of  fistula  in  auoy  which  are  usually  tuberculous.  When  it  is  not 
desirable  to  use  the  knife,  medicated  injections  can  often  be  used  to 
advantage. 

Among  the  solutions  which  can  be  employed  for  this  purpose  are : 
tincture  of  iodin  used  in  full  strength  or  more  or  less  diluted  ;  carbolic 
acid  (i  :  200),  or  phenyl  (1  :  250).  A  10  per  cent,  emulsion  of  iodo- 
form in  glycerin,  and  Krause's  emulsion,  which  also  contains  gum 
arabic  and  carbolic  acid,  are  valuable  remedies.  Fistulas  remain  often 
for  many  months  after  abdominal  operations.  These  are  due  either  to 
infected  ligatures  or  to  the  communication  of  a*  sinus  with  the  bowel 
or  the  Fallopian  tubes.  These  fistuhe  often  eventually  heal  sponta- 
neously. If  it  is  decided  to  operate  upon  them,  they  should  either  be 
curetted  with  great  care,  so  as  not  to  open  the  peritoneal  cavity,  or  an 
opening  should  be  made  near  them  into  the  peritoneal  cavity,  which 
should  then  be  walled  off.  The  track  of  the  sinus  or  fistula  can  then 
be  traced  to  its  source,  and  the  diseased  tissue  can  often  be  excised. 

Attention  should  be  given  in  all  cases  to  the  general  condition  of 
the  patients  and  their  surroundings.  A  chronic  fistula  will  often  heal 
after  some  intercurrent  disease,  such  as  scarlet  fever  or  typhoid  fever. 
A  thorough  change  in  the  habits  of  the  patient  may  also  bring  about 
the  same  result. 


CHAPTER    IV. 
SURGICAL   PATHOLOGY   OF   THE   BLOOD. 

The  examination  of  the  blood  throws  so  much  light  upon  the  con- 
dition of  surgical  patients  as  to  make  it  a  useful  rule  that  every  patient's 
hemoglobin  shall  be  tested  once  a  week  (Mikulicz).  This  is  done 
partly  to  watch  the  progress  of  patients  after  bloody  operations,  and 
partly  to  ascertain  whether  it  is  advisable  to  operate  upon  patients 
already  very  anemic. 

Blood-regeneration  After  Operation. —  i.  Mikulicz  finds  that 
the  length  of  time  needed  for  full  restoration  of  the  blood  to  normal 
depends  on  :  (a)  the  amount  of  blood  lost ;  (b)  the  age  and  nutrition 
of  the  patient  (those  at  the  extremes  of  life  bear  hemorrhage  badly) ; 
(c)  the  existence  of  other  diseases  (cancer,  tubercle,  typhoid) ;  (d)  the 
treatment. 

Other  conditions  being  favorable,  he  finds  that  a  loss  of 

Under  I  per  cent,  of  the  blood-mass  is  made  up  in  from  2  to  5  days. 

From  I  per  cent,  to  3  per  cent,  of  the  blood-mass  is  made  up  in  from    5  to  14  days. 

From  3  per  cent,  to  4  per  cent,  of  the  blood-mass  is  made  up  in  from  14  to  30  days. 

Few  surgical  operations  involve  a  loss  of  over  3  per  cent.,  and 
accordingly  in  a  normal  adult  individual  under  favorable  conditions 
we  expect  the  blood  to  be  normal  within  two  weeks  from  the  time  of 
operation.  If  it  is  not  so  we  suspect  some  deeper  cause  for  the  de- 
layed regeneration — e.  g.  cancer.  Bierfreund  noticed  that  after  oper- 
ations for  malignant  disease  the  blood  does  not  begin  to  be  regen- 
erated until  considerably  later  than  after  other  operations — a  week 
later  on  the  average — and  that  it  never  reached  as  high  a  point  as  it 
had  before  operation.  This  assertion  of  Bierfreund's,  based  upon  many 
cases  watched  during  long  periods,  is  all  the  more  extraordinary 
because  some  of  his  cases  made  a  marked  gain  in  weight  and  appeared 
to  be  greatly  improved  in  other  respects  after  the  operation.  So  far 
as  I  know  there  has  been  neither  confirmation  nor  contradiction  of 
Bierfreund's  data. 


Diagnosis. 

Per  cent.  Hb. 
before  operation. 

Per  cent.  Hb. 
after  operation. 

Loss. 

Time   elapsing   before 
Hb.  begins  to  rise. 

Malignant  tumors  without  ] 
complications.                    j 

Very  large  or  rapidly  "1 
growing   tumors.               ] 

Tumors  with  softening  or  \ 
marked  disturbance  of  \ 
function.                              J 

68.5 
56.6 

57-5 

53 
38.4 

39-7 

15-5 
18.2 

17.8 

23      days. 
27.8  days. 

27      days. 
Average,  25.9  days. 

In  72  cases  of  malignant  disease  Bierfreund  noted  the  percentage 
of  hemoglobin  daily  after  the  operation  to  discover  how  many  days 


80 


SURGICAL    PATHOLOGY  OF   THE  BLOOD.  8 1 

elapsed  before  the  hemoglobin  began  to  rise.  In  ordinary  operations 
the  blood  begins  to  be  regenerated  in  from  five  to  twenty  days.  The 
table  given  on  page  80  shows  the  conditions  found  in  72  cases  of 
malignant  disease. 

2.  Mikulicz  makes  it  a  rule  never  to  operate  on  a  patient  whose 
hemoglobin  is  under  30  per  cent.  This  gives  him  a  standard  up  to 
which  patients  must  be  brought  by  treatment  and  rest  before  he  will 
subject  them  to  further  loss  of  blood.  Surgeons  would  do  well,  in 
many  accident  cases  where  much  blood  has  been  lost,  to  assist  their 
judgment  as  to  operating  or  waiting  by  some  objective  test  like  Miku- 
licz's 30  per  cent,  of  hemoglobin. 

Importance  of  Blood-examination  in  Accident  Cases  with 
Shock  or  Hemorrhage. —  I.  How  often  one  hears  the  question  dis- 
cussed in  the  accident  room  of  any  hospital  whether  to  operate  at  once 
or  wait  till  the  patient  has  got  over  the  "  shock."  The  question  is  not 
often  asked  (far  less  answered)  whether  the  "shock"  is  simply  or 
largely  anemia  (cerebral  and  general)  from  loss  of  blood,  or  whether  it  is 
of  nervous  origin — /.  e.,  due  to  concussion,  compression,  etc.  The  right 
decision  of  this  question  is  of  great  importance,  for  if  the  "  shock  " 
means  anemia,  transfusion  may  be  indicated,  while  in  a  condition  of 
cerebral  concussion  or  compression  transfusion  will  probably  do  harm. 
An  examination  of  the  blood  enables  us  in  certain  cases  to  decide  such 
a  question.  That  is,  if  the  number  of  red  cells  is  considerably  dimin- 
ished— 3,500,000  or  less — and  if  the  patient  is  known  not  to  have 
been  previously  anemic,  the  "  shock  "  probably  means  hemorrhage. 

2.  Aside  from  the  question  of  whether  any  hemorrhage  has  taken 
place,  the  blood-count  may  enable  us  to  gauge  approximately  the 
amount  of  hemorrhage.  Here  it  should  be  remembered,  however, 
that  immediately  after  hemorrhage  the  count  may  be  normal,  since 
only  the  amount  and  not  the  quality  of  the  blood  is  affected.  Within 
a  few  hours,  however,  fluid  is  absorbed  from  the  tissues  into  the  vessels, 
and  then  the  amount  of  anemia  is  indicated  by  the  blood-count. 

3.  Internal  or  concealed  hemorrhage  in  obstetric  cases,  extra-uterine 
pregnancy,  ruptured  aneurysm,  laceration  of  the  spleen,  kidney,  liver, 
etc.,  can  sometimes  be  diagnosed  by  the  blood-examination.  A  man 
recently  entered  the  Massachusetts  General  Hospital  with  acute  pul- 
monary symptoms  resembling  pneumonia,  and  died  before  any  diag- 
nosis could  be  arrived  at.  The  point  inconsistent  with  pneumonia  was 
the  low  blood-count — 3,324,000  red  cells  with  33  per  cent,  of  hemo- 
globin— and  this  in  a  man  previously  well  and  not  anemic  should,  I 
think,  have  suggested  hemorrhage  somewhere.  Autopsy  showed  a 
ruptured  aortic  aneurysm. 

In  the  diagnosis  between  pus-tube  and  hematocele,  between  hemo- 
thorax and  pleurisy,  I  have  found  the  blood-count  useful  in  a  similar 
way. 

Abscess  and  Deep-seated  Suppuration. — Almost  all  acute 
and  subacute  suppurative  processes  in  any  part  of  the  body  manifest 
themselves  in  the  peripheral  blood  by  an  increase  in  the  number  of 
polymorphonuclear  leukocytes.  It  matters  not  whence  the  blood  is 
taken,  whether  from  a  part  near  the  suppurating  point  or  at  a  distance. 
For  instance,  in  a  felon  the  blood  from  the  ear  shows  as  great  a  leuko- 


82  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

cytosis  as  that  from  a  ringer  next  the  one  affected  ;  and  in  suspected 
middle-car  abscess  blood  from  the  ear  shows  the  same  number  of 
leukocytes  as  that  from  the  finger. 

1.  The  degree  of  leukocytosis  is  independent  of  the  amount  of  pus. 
A  felon  may  raise  the  leukocyte-count  as  much  as  an  empyema. 

2.  An  increasing  leukocytosis  points  to  a  spreading  process,  and 
may  be  the  only  evidence  of  it.  In  several  cases  of  appendicitis  where 
the  subsidence  of  pain,  tenderness,  temperature,  and  pulse-rate  seemed 
to  point  to  a  subsiding  process,  but  where  the  leukocyte-count  steadily 
rose,  the  subsequent  operation  has  proved  the  indications  given  by  the 
blood  to  be  correct.  In  this  connection  it  should  be  stated  that  a 
leukocytosis-^//**?/-/  showing  the  increase  or  decrease  from  day  to  day  is 
as  much  more  valuable  than  a  single  count,  as  a  temperature-chart  is 
more  valuable  than  a  single  temperature  record.  It  is  the  rise  or  fall 
of  the  count  that  oftenest  helps  us  in  diagnosis,  not  the  single  count. 

3.  Occasionally  leukocytosis  is  absent  despite  the  presence  of  a 
considerable  quantity  of  pus.  This  is  a  rare  occurrence,  but  when  it 
does  occur,  is  of  considerable  importance.     It  happens : 

(a)  In  cases  in  which  the  bacteria  in  the  pus  have  died. 

(o)  In  cases  where  the  pus  is  very  thoroughly  walled  off. 

Either  of  these  conditions  means  that  the  process  is  at  a  standstill, 
and  that  the  pus  is  acting  simply  as  a  foreign  body  and  not  as  a  center 
of  infection. 

(e)  In  fulminating  cases  of  extreme  severity  in  which  the  patient 
succumbs  without  offering  any  considerable  resistance  to  the  action  of 
the  infection.  For  example,  in  6  cases  of  rapidly-fatal  general  peri- 
tonitis I  have  found  the  leukocyte-count  normal.  In  68  other  cases 
of  general  peritonitis  and  in  hundreds  of  other  suppurative  affections  I 
have  never  failed  to  find  leukocytosis  except  on  the  conditions  just 
mentioned  in  (c?)  and  (//)  above.  The  failure  of  the  leukocytes  to  react 
in  fulminating  septic  cases  is  similar  to  their  behavior  in  the  worst  cases 
of  p'neumonia,  diphtheria,  and  .some  other  infections.  Generalizing  these 
facts,  it  appears  that : 

I.  In  the  very  mildest  and  the  very  severest  cases  there  is  no  leuko- 
cytosis. 

II.  In  the  vast  majority  of  the  whole  range  of  cases — i.  c,  those  of 
moderate  severity — leukocytosis  appears. 

In  other  words,  it  appears  as  if  leukocytosis  were  present  whenever 
there  is  a  hard  fight  between  the  attacking  infection  and  the  resisting 
powers  of  the  system — i.  e.,  in  over  90  per  cent,  of  all  cases  ;  while  if 
there  is  an  overwhelming  victory  either  for  the  system  or  for  the  infec- 
tion, the  leukocytes  are  not  multiplied. 

4.  When  drainage  is  established  and  free  exit  given  to  the  pus  of  an 
abscess,  the  leukocyte-count  usually  falls  rapidly  to  or  nearly  to  normal. 
As  soon  as  a  wall  of  granulation-tissue  is  established  between  the 
abscess-cavity  and  the  tissues  in  which  it  is  situated,  the  leukocytes 
become  normal  and  remain  so,  provided  the  drainage  is  free  and  suffi- 
cient, even  when  the  amount  of  pus  discharged  is  large.  If  this  wall 
of  granulation-tissue  is  broken  down  by  curetting,  probing,  or  even  by 
the  removal  of  stitehes,  the  leukocyte-count  will  rise  again.  Pocketing 
of  pus  or  anything  approaching  it  is  shown  by  a  similar  rise. 


SURGICAL    PATHOLOGY  OF    THE   BLOOD.  83 

5.  Other  things  being  equal,  we  get  the  greatest  degree  of  leukocy- 
tosis in  the  most  virulent  infections  well  resisted  by  the  system  and 
independent  of  the  number  of  cells  in  the  exudation.  A  general  peri- 
tonitis, showing  only  turbid  serum  and  fibrin-flakes  as  a  product,  may 
produce  as  high  a  count  as  one  in  which  the  abdomen  is  full  of  thick 
pus.  A  gangrenous  appendicitis  or  a  diphtheritic  endometritis  may  raise 
the  count  higher  than  an  abscess  containing  quarts  of  pus.  Not 
the  product  but  the  violence  of  the  infection  governs  the  amount  of 
leukocytosis. 

Average  cases  of  appendicitis, abscess,  or  pus-tube  show  from  1 5,000 
to  30,000  leukocytes  per  c.mm.  Counts  larger  than  this  mean  a  case 
of  the  greatest  severity.  Catarrhal  appendicitis  does  not  raise  the 
count  above  15,000. 

6.  The  count  of  leukocytes  is  of  especial  value  in  cases  of  deep- 
seated  suppuration,  such  as  osteomyelitis  and  hepatic  or  perinephritic 
abscess.  In  the  latter  affections  I  have  repeatedly  seen  the  diagnosis 
suggested  by  the  leukocyte-count  at  an  early  stage  of  the  disease,  when 
practically  no  pain  or  fever  was  present. 

Purulent  accumulations  in  a  cerebral  sinus  following  middle-ear 
trouble  sometimes  show  themselves  through  the  blood-count  when 
there  is  nothing  else  to  suggest  the  diagnosis.  The  differential  diag- 
nosis between  suppurative  and  non-suppurative  pelvic  disease  in  women 
is  sometimes  materially  aided  by  the  positive  or  negative  indication 
given  by  the  blood. 

In  many  surgical  cases  the  elevations  of  temperature  following 
operation  appear  sometimes  due  to  "nervousness"  or  other  mental 
disturbance.  In  such  cases  the  blood-count  is  unaffected,  while  if  the 
temperature  is  due  to  sepsis  or  deficient  drainage,  the  leukocytes  are 
increased. 

Other  affections  which  may  cause  symptoms  suggesting  pus,  but 
which  do  not  raise  the  leukocyte-count,  are  (a)  the  various  colics — 
intestinal,  uterine,  hepatic,  renal ;  (£>)  typhoid  fever,  in  which  resem- 
blance to  appendicitis  is  sometimes  puzzling;  (r)  floating  kidney;  (d) 
fecal  impaction  or  simple  constipation;  (e)  ovarian  or  pelvic  neuralgia; 
(_/")  an  attack  of  grippe,  or  malaria  occurring  during  convalescence  from 
a  surgical  operation.  These  complications  may  cause  a  great  deal  of 
anxiety  from  the  similarity  of  some  of  the  symptoms  to  those  of  severe 
sepsis,  but  neither  of  them  affects  the  leukocytes  ;  [the  detection  of 
the  malarial  organism  is  a  valuable  bit  of  evidence].  (^)  Serous 
pleuritic  effusions  do  not  raise  the  leukocyte-count  appreciably  in 
the  great  majority  of  cases.  Purulent  pleurisy  [empyema]  almost 
always  does. 

Tuberculosis. — Pure  tubercular  infections  uncomplicated  by 
pyogenic  organisms  do  not  affect  the  blood  to  any  extent.  The  only 
exception  to  this  is  tubercular  meningitis,  which  sometimes  is  and 
sometimes  is  not  accompanied  by  leukocytosis,  the  reason  for  this 
variation  being  as  yet  unknown.  "  Cold  abscesses  "  which  have  been 
opened,  and  so  infected  with  pyogenic  cocci,  show  a  leukocytosis  at 
once.  In  hip  or  spinal  tuberculosis  an  increasing  leukocytosis  means 
either  abscess-formation  or  an  increased  activity  in  the  tubercular 
process. 


84  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Tubercular  peritonitis  can  be  differentiated  from  other  varieties  of 
peritonitis  by  its  normal  blood-count. 

Malignant  Disease. — The  differential  diagnosis  between  malig- 
nant disease  on  the  one  hand  and  tuberculosis  or  abscess  on  the  other 
is  sometimes  greatly  assisted  by  the  examination  of  the  blood. 

As  between  malignant  disease  and  abscess  or  tubercle,  the  presence 
of  marked  deformities  in  the  red  cells,  or  of  nucleated  red  cells,  favors 
malignant  disease.  Only  occasionally  in  the  severest  forms  of  sepsis 
or  tuberculosis  do  we  find  these  changes  in  the  red  corpuscles,  and 
then  always  associated  with  great  anemia  ;  while  in  malignant  disease 
they  are  more  often  present,  even  without  extreme  anemia.  Positive 
evidence  is,  however,  of  far  greater  value  than  negative  in  such  cases, 
since  the  red  cells  are  often  not  affected  in  cancer  until  the  later  stages 
are  reached. 

The  leukocytes  in  perhaps  the  majority  of  cases  of  early  cancer  are 
not  increased  in  number,  though  the  polynuclear  varieties  may  be  in  ex- 
cess, a  fact  of  the  same  significance  as  an  increase  in  the  whole  number. 

The  cases  in  which  the  total  count  is  increased  are  usually,  though 
not  always,  those  in  which  the  new  growth  is  extensive  and  rapidly 
spreading,  so  that  its  presence  could  be  determined  without  the  trouble 
of  making  a  blood-examination. 

Thus  the  majority  of  cases  of  early  mammary,  gastric,  and  labial 
cancer  show  no  blood-changes. 

Between  cancer  and  tubercle  the  presence  of  leukocytosis  points 
toward  the  former,  while  its  absence  is  consistent  with  either  diagnosis. 
The  importance  of  the  red  cells  in  this  question  has  already  been 
mentioned. 

Between  cancer  and  abscess  the  leukocytes  do  not  help  us,  except 
that  if  there  is  no  increase  it  is  probably  not  abscess.  In  the  presence 
of  a  leukocytosis  we  can  sometimes  get  some  aid  in  the  diagnosis 
between  cancer  and  abscess  by  an  examination  of  the  amount  of  fibrin 
seen  in  the  microscopic  field  as  a  drop  of  blood  slowly  dries  between 
a  slide  and  cover-glass.  Fibrin  is  usually  increased  in  abscess,  and  not 
in  cancer.  Deformed  or  nucleated  red  cells  would  incline  us  toward 
the  diagnosis  of  cancer. 

Sarcoma  is  much  more  frequently  accompanied  by  leukocytosis 
than  cancer  is.  This  is  especially  true  of  osteosarcoma  and  renal 
sarcoma.  In  these  affections  the  counts  may  run  very  high,  even  to 
1 00,000  per  c.mm.  Between  osteosarcoma  and  tuberculosis  the  pres- 
ence of  leukocytosis  favors  the  former,  and  its  absence  the  latter.  I 
have  in  2  cases  seen  a  sarcoma  of  the  left  kidney  mistaken  for  leuke- 
mia, on  account  of  the  resemblance  of  the  tumor  to  an  enlarged  spleen 
and  the  great  increase  in  the  number  of  white  cells.  Of  course,  the 
kind  of  white  cells  that  are  increased  differs  absolutely  in  the  two 
cases,  and  a  glance  at  the  stained  specimen  will  settle  the  diagnosis ; 
but  without  the  stained  specimen  no  diagnosis  between  the  two  affec- 
tions is  possible  in  all  cases.     (See  Leukemia.) 

Jaundice. — Owing  to  slow  coagulation  of  the  blood  in  certain 
cases  of  jaundice,  it  is  advisable  before  operating  on  such  cases  to  test 
the  coagulation-time  (by  Wright's  method),  and  to  modify  one's  prog- 
nosis and  treatment  if  the  coagulability  is  markedly  deficient. 


SURGICAL    PATHOLOGY  OF   THE  BLOOD.  85 

I/euketnia. — Within  two  years  the  writer  has  seen  a  well-known 
surgeon  cut  down  upon  a  leukemic  liver  to  make  sure  that  it  was  leu- 
kemic. This  is  absolutely  inexcusable.  The  diagnosis  of  leukemia  can 
be  made  with  absolute  certainty  by  the  blood-examination  alone,  and  had 
been  so  made  in  this  case.  Any  case  with  chronic  enlargement  of  the 
spleen  or  lymphatic  glands  demands  a  careful  blood-examination,  with 
the  aid  of  which  no  diagnosis  in  medicine  is  easier  than  that  of  leukemia. 

The  confusion  of  leukocytosis  with  leukemia,  although  their  differ- 
ence has  been  frequently  pointed  out,  is  still  perpetuated  through  the 
carelessness  of  text-book  writers.  The  distinction  lies  not  in  the 
number  of  leukocytes  nor  in  the  duration  of  the  increase  (since  leuko- 
cytosis not  infrequently  shows  a  higher  count  than  leukemia,  and  may 
last  longer),  but  in  the  kind  of  leukocyte  increased.  In  leukocytosis 
only  the  polynuclear  forms  are  increased  ;  in  leukemia  it  is  the  lympho- 
cytes or  myelocytes  that  make  up  the  bulk  of  the  increase.  In  the 
fresh  specimen  examined  between  slide  and  cover-glass  or  in  the 
Thoma-Zeiss  counting-chamber,  the  distinction  of  the  different  kinds 
of  leukocytes  is  not  practicable.  Only  in  the  stained  cover-slip  prepa- 
rations can  the  differences  be  properly  seen.     (See  Plate  4.) 

Lymphatic  leukemia  sometimes  causes  only  a  moderate  swelling 
of  the  external  lymph-glands,  and  under  these  circumstances  may  be 
mistaken  for  tubercular  or  syphilitic  lymphadenitis.  The  diagnosis  is 
perfectly  simple  provided  we  do  not  forget  the  blood-examination  or 
exclude  leukemia  because  of  the  slight  enlargement  of  the  glands. 
This  mistake  is  especially  apt  to  occur  with  the  gastro-intestinal  form 
of  leukemia,  in  which  the  only  external  glandular  enlargement  is  in 
the  neck. 

Pseudoleukemia,  or  Hodgkin's  Disease. — The  post-mortem 
appearances  are  in  all  respects  identical  with  those  of  leukemia,  and 
the  two  diseases  differ  only  in  the  blood-condition.  Hodgkin's  disease 
shows  normal  blood  during  the  greater  part  of  its  course.  Toward  the 
end  a  slight  leukocytosis  may  appear,  but  there  is  never  the  slightest 
resemblance  to  leukemic  blood.  The  reported  transitions  from  the 
one  disease  to  the  other  are  probably  mythical.  Hodgkin's  disease  is 
usually  known  to  surgeons  as  lymphoma,  lymphadenoma,  lympho- 
sarcoma, or  malignant  lymphoma.  The  confusion  of  terms  is  unavoid- 
able, since  there  appear  to  be  no  reliable  differentiae,  either  gross  or 
microscopic,  between  sarcoma  of  the  lymph-glands,  lymphoma,  and 
Hodgkin's  disease.  The  surgeon's  chief  interest  in  such  cases  is  in 
distinguishing  Hodgkin's  disease  from  leukemia,  and  this  he  can  very 
easily  do  from  the  blood-examination. 

The  more  rapid  the  advance  of  the  disease  the  more  likely  is  it 
that  the  polynuclear  leukocytes  will  be  somewhat  increased.  Most 
cases  run  a  long  course — five  to  ten  years — and  in  such  the  blood 
remains  normal  till  near  the  end.  On  the  other  hand,  I  recently 
watched  a  case  which  ran  its  entire  course  in  six  weeks,  and  in  which 
there  was  always  some  polynuclear  leukocytosis. 

Bacteriology  of  the  Blood  in  Pyemia  and  Septicemia. — In 
a  certain  proportion  of  severe  septic  cases,  such  as  those  following 
wound  infection  and  puerperal  cases,  the  bacteriological  examination 
of  a  syringeful  of  blood  taken   from  a  vein  at  the  bend  of  the  elbow 


86  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

gives  some  information  as  to  diagnosis,  prognosis,  and  treatment.  Not 
all  cases,  however,  even  of  the  severest  type,  show  any  bacteria  in  the 
peripheral  circulation. 

The  blood  may  be  taken  with  any  ordinary  hypodermic  syringe. 
This  is  sterilized  by  heat.  The  bend  of  the  elbow  is  rendered  aseptic 
as  if  for  operation,  and  all  traces  of  the  antiseptics  used  washed  off 
with  boiled  water.  Pressure  above  the  elbow  makes  the  veins  stand 
out,  and  into  any  one  of  them  the  needle  of  the  syringe  may  be  plunged 
directly  without  any  preliminary  dissection.  The  piston  is  then  with- 
drawn until  the  barrel  of  the  syringe  is  filled.  After  pulling  out  the 
needle  moderate  pressure  prevents  all  hemorrhage,  and  within  an  hour 
or  two  there  is  no  discomfort  left.  The  pain  caused  is  hardly  greater 
than  that  of  an  ordinary  hypodermic  injection. 

Blood  so  collected  is  poured  over  the  surface  of  2  or  3  blood-serum 
"  slants  "  and  cultivated  in  the  thermostat. 

The  presence  of  the  streptococcus  or  the  golden  staphylococcus  is 
almost  always  equivalent  to  a  fatal  prognosis.  The  presence  of  the 
Staphylococcus  albus  is  of  slight  importance,  being  usually  due  to 
contamination. 

The  presence  of  the  streptococcus  may  be  an  indication  for  a  trial 
of  the  antistreptococcus  serum. 

Aseptic  Post-operative  Fever. — In  a  certain  number  of  cases, 
after  operations  in  which  the  wound  is  closed  without  drainage,  a  cer- 
tain amount  of  fever  is  present  for  a  few  days,  even  where  the  wound 
eventually  heals  by  first  intention.  Such  cases  are  accompanied  by 
moderate  leukocytosis,  and  the  presence  of  such  an  increase  after  oper- 
ation cannot  afford  any  presumption  that  the  wound  will  "  go  septic." 
Presumably  there  are  bacteria  in  every  healing  wound,  even  in  those 
that  heal  by  first  intention,  and  the  presence  of  these  organisms, 
together  with  the  setting  free  of  nuclein  from  the  cells  destroyed  at 
the  operation  and  in  the  healing  process,  is  sufficient  to  account  for  the 
leukocytosis. 

Fractures. — The  majority  of  simple  fractures  do  not  affect  the 
blood,  but  in  a  certain  number  of  cases  they  are  followed  by  leuko- 
cytosis. In  two  of  these  cases  I  have  known  thrombosis  to  follow. 
Whether  this  was  a  mere  coincidence  or  whether  thrombosis  is  really 
more  likely  to  occur  in  cases  where  leukocytosis  is  present,  I  cannot 
say. 

Iyymph- scrotum  and  Chyluria. — The  presence  in  the  blood  of 
the  embryo  of  the  Filaria  sanguinis  hominis,  while  often  unattended 
with  any  symptoms  or  signs,  may  be  associated  with  a  chylous  urine, 
a  chylous  hydrocele,  or  elephantiasis  of  one  region  or  another.  These 
conditions  are  caused  by  the  presence  of  the  adult  filaria  in  the  lymph- 
vessels.  It  seems  to  have  a  special  fondness  for  the  lymphatics  of  the 
urogenital  tract.  The  wall  of  the  lymphatic  is  inflamed  and  the  lymph- 
flow  is  obstructed. 

The  embryo  filaria  is  usually  present  in  large  numbers  in  the  gen- 
eral circulation,  and  can  be  seen  in  fresh  slide-and-cover-glass  speci- 
mens. Its  presence  is  first  noticed  by  the  disturbance  among  the 
neighboring  corpuscles,  which  are  knocked  about  by  the  lashing  of 
the  filaria's    tail.      It  is  apt  to  be  present  in   the    peripheral    circula- 


Plate  4. 


4kxt 


f  \    £ 


m 


€te 


"''■-"* 
i»;.:>  :•*. 


&* 


-S/na?/  Lymphocyte 


Large  Lymphocyte. 


Leukocytosis  (60,000)  :  coversiip  specimen;  Ehrlich's  triacid  stain.  The  red  corpuscles 
are  stained  yellow;  all  the  others,  except  those  labelled,  are  polymorphonuclear  neutro- 
philes. 


SURGICAL   PATHOLOGY  OF  THE   BLOOD.  S? 

tion  only  at  night,  so  that  this  time  should  be  selected  for  the  exami- 
nation. The  embryo  worm  is  about  40//  in  length,  and  about  5  to  10// 
in  diameter,  with  a  blunt  head  and  a  pointed  tail,  the  whole  organism 
being  enclosed  in  a  translucent  sheath  which  can  be  seen  projecting 
beyond  the  extremities  of  the  body.  The  organism  is  easily  stained 
with  fuchsin  and  other  ordinary  stains. 

Not  all  cases  of  chyluria,  lymph-scrotum,  or  elephantiasis  are  due 
to  this  worm,  for  the  lymphatics  may  be  blocked  by  other  causes. 
But  every  case  should  be  examined  for  the  filaria,  and  in  the  majority 
of  cases  it  will  be  found. 

Hemophilia. — A  tendency  to  bleeding  from  any  surface  of  the 
body,  occurring  either  spontaneously  or  from  slight  trauma,  such  as  a 
scratch  or  bruise. 

Etiology, — The  disease  is  at  least  twelve  times  more  frequent  in 
males  than  in  females,  and  where  it  occurs  in  females  it  is  usually  of 
a  mild  type.  It  is  almost  always  hereditary,  but  the  mode  of  trans- 
mission is  remarkable  in  that  it  is  through  the  females,  but  to  the 
males,  as  a  rule. 

Though  the  disease  may  show  itself  from  the  time  of  birth,  it  is 
usually  not  until  the  first  kw  years  of  life  are  past  that  it  shows  itself. 
It  is  especially  apt  to  cause  trouble  during  dentition  and  at  puberty, 
but  70  per  cent,  of  the  cases  appear  before  the  fifth  year.  It  rarely  be- 
gins in  adult  life.     The  actual  cause  of  the  disease  is  unknown. 

Symptoms. — In  the  severest  cases  hemorrhages  occur  spontane- 
ously or  from  the  slightest  trauma.  They  may  be  confined  to  the  skin 
or  to  the  mucous  surfaces,  or  ma}'  extend  to  the  serous  surfaces. 
Occasionally  blood  is  poured  out  in  the  interior  of  various  organs. 
Spontaneous  hemorrhage  is  especially  apt  to  occur  in  the  scalp  or  the 
genital  region  (Treves).  The  oozing  may  cease  within  a  few  minutes 
spontaneously  or  under  treatment,  or  it  may  go  on  for  days  or  even 
weeks.  When  the  hemorrhage  can  be  checked  it  is  well  borne,  and 
the  restitution  occurs  quickly;  but  the  pulling  of  teeth,  circumcision,  or 
even  a  slight  scratch  may  occasion  a  fatal  hemorrhage. 

Hemorrhage  may  take  place  into  joints,  and  be  attended  with  pain, 
swelling,  and  fever.  No  characteristic  changes  are  found  in  the  blood. 
The  anemia  is  like  that  seen  after  any  other  hemorrhage. 

Prognosis — Some  cases  are  fatal  within  twenty-four  hours.  The 
tendency  may  disappear  in  adult  life  if  the  patient  can  be  piloted  safely 
through  childhood.  Death  may  occur  either  from  hemorrhage  or  from 
some  intercurrent  infection,  to  which  such  patients  are  naturally  very 
liable. 

Treatment — Prophylaxis  is  of  the  first  importance.  The  child 
should  be  carefully  guarded  from  scratches,  cuts,  and  bruises,  no  teeth 
should  be  extracted,  and  every  possible  occasion  for  bleeding  avoided. 
Should  hemorrhage  occur,  gauze  soaked  in  perchlorid  of  iron  should 
be  applied,  and  firm  pressure  exerted  and  continued  as  long  as  is  neces- 
sary. The  internal  administration  of  such  drugs  as  ergot,  gallic  acid, 
and  lead  acetate  is  probably  useless.  The  anemia  should  be  combated 
in  the  ordinarv  manner  and  the  creneral  health  carefullv  attended  to. 


CHAPTER   V. 

WOUNDS  AND  CONTUSIONS;  BURNS  AND  SCALDS; 
EFFECTS  OF  LIGHTNING;  SHOCK;  FAT-EMBOLISM; 
REPAIR  OF  SPECIAL  TISSUES. 

WOUNDS. 

Definition. — A  wound  is  the  forced  separation  of  any  portion  of 
the  skin  or  mucous  membrane  in  which  the  protecting  covering  of  the 
underlying  tissues  is  destroyed  and  the  latter  exposed  to  the  influence 
of  the  air  and  other  extraneous  matters. 

Classification  and  Mechanism. — Wounds  of  the  surface  involv- 
ing exposure  of  the  subcutaneous  connective  tissue  are  divided,  ac- 
cording to  the  conditions  of  their  edges,  into  the  following : 

1.  Those  with  well-defined  and  sharp  edges.  These  are  subdivided 
into  incised  and  punctured  wounds. 

2.  Lacerated  solutions  of  continuity  of  the  surface.  These  are 
known  as  lacerated  wounds.  They  occur  when  there  is  excessive  ten- 
sion upon  the  skin  by  the  application  of  a  dragging  force,  or  where  the 
tissues  are  forced  against  some  underlying  hard  or  unyielding  part,  as, 
for  instance,  the  skull. 

3.  Contused  breaches  of  tissue.  These  are  known  as  contused 
wounds.  They  are  caused  by  an  object  with  a  broad  surface  coming  in 
contact  with  a  portion  of  the  body,  or  by  falls  upon  hard  irregular  sur- 
faces. Wounds  following  the  blow  of  a  club,  or  the  entrance  of  some 
missile  into  the  body,  as,  for  instance,  those  from  firearms  (gunshot 
wounds),  are  familiar  examples  of  contused  wounds. 

Other  classifications  include  penetrating  wounds,  which  are  caused 
by  a  foreign  body  entering  a  cavity  of  the  body  without  emerging,  and 
perforating  wounds,  in  which,  having  penetrated  a  portion  of  the  body, 
it  again  emerges.  When  some  specific  poison  has  entered  the  wound 
at  the  time  of  its  infliction,  it  is  spoken  of  as  a  poisoned  wound.  When 
wounds  have  been  infected  with  those  organisms  which  excite  putrefac- 
tion and  disorganization  of  tissue,  they  are  said  to  be  septic  wounds. 
In  the  absence  of  such  infection  the  wound  is  said  to  be  aseptic.  More 
or  less  destruction  of  tissue  characterizes  all  wounds. 

Symptoms. — The  three  cardinal  symptoms  of  a  wound  are  (i)  sepa- 
ration and  gaping  of  its  edges  ;  (2)  hemorrhage  ;  (3)  pain. 

Separation  and  Gaping  of  the  Wound=edges. — This  results  from 
the  presence  of  elastic  fibers  in  the  connective  tissue  and  cutis.  It  em- 
phasizes the  elasticity  characteristic  of  the  uninjured  skin.  The  degree 
of  the  separation  of  the  wound-edges  depends  upon  the  number  and 
direction  of  the  elastic  fibers  and,  in  addition,  upon  the  depth  of  the 
wound  itself  and  its  direction.     If  the  latter  be  parallel  to   that  of  the 

88 


WOUNDS.  89 

elastic  fibers  of  the  skin  and  connective  tissue  the  separation  will  be 
comparatively  slight.  Upon  the  other  hand,  if  the  elastic  fibers  are 
separated  in  a  transverse  direction  the  separation  will  be  greater. 
Wounds  with  considerable  depth  gape  more  than  those  that  are  merely 
superficial. 

Hemorrhage. — The  hemorrhage  which  ensues  upon  the  infliction 
of  a  wound  depends  upon  the  size  and  condition  of  the  divided  blood-; 
vessels,  as  well  as  upon  the  depth,  length,  and  breadth  of  the  wound. 
This  symptom  varies  greatly  in  different  wounds  of  the  same  variety, 
as  well  as  in  different  kinds  of  wounds.  As  a  rule,  it  is  less  marked  in 
contused  and  lacerated  wounds  than  in  those  with  clean-cut  and  sharply 
defined  edges. 

Pain. — Pain  is  the  usual  immediate  accompaniment  of  a  wound, 
and  results  from  the  coincident  injury  and  subsequent  irritation  of  sen- 
sory nerve-fibers  in  the  injured  tissues.  Its  character  is  usually  de- 
scribed as  "sharp"  or  "  burning."  It  is  felt  in  the  area  of  distribution 
of  the  nerve  or  along  the  trunk  of  the  latter.  The  pain  varies,  also, 
with  the  mechanism  of  the  production  of  the  wound.  If  the  nerve- 
fibers  are  rapidly  and  thoroughly  divided,  the  pain,  as  a  rule,  is  less. 
The  wound  may  be-  inflicted  so  suddenly  and  rapidly  that  no  pain 
whatever  is  experienced.  Mental  excitement  at  the  time  of  the  injury 
likewise  lessens  the  pain.  The  pain  may  also  vary  with  the  variety  of 
wound  inflicted.  In  clean  incised  wounds  the  wounded  person  may 
not  be  aware  that  he  is  injured  until  his  attention  is  attracted  to  the 
wounded  part  by  the  presence  of  blood.  Contused  wounds  are  the 
most  painful  of  injuries.  Certain  conditions  of  temperament  exert 
restraining  influences  upon  sensory  nerves  and  the  cortical  centers. 
For  instance,  courageous  persons  and  those  in  a  furious  rage,  on  the 
one  hand,  and  those  who  exercise  a  quiet  self-control,  on  the  other, 
suffer  least  from  the  pain  of  an  injur}-. 

Clinical  Course. — Wounds  in  which  the  edges  are  sharply  de- 
fined and  but  slightly  separated  may  heal  in  a  comparatively  short 
time  without  any  essential  change  being  observed  in  their  surroundings. 
The  interspace  is  filled  by  a  very  narrow  coagulum  which  causes 
agglutination  of  the  wound-edges.  The  upper  layer  of  the  coagulum 
projects  just  beyond  the  edges ;  this  becomes  dried  and  forms  a  thin 
linear  scab.  This  scab  exercises  a  hermetically  sealing  effect  upon  the 
wound.  Very  slight  violence  may  reopen  the  wound  in  the  earlier 
stage  of  this  reparative  process.  As  organization  takes  place  in  the 
thin  cement  of  blood-clot,  the  union  of  the  wound-edges  through  the 
medium  of  this  becomes  more  firm,  until  the  thin  and  narrow  surface- 
scab  falls  off,  leaving  a  dark-blue  groove  covered  with  epidermis  in  the 
process  of  formation.  This  is  called  the  cicatrix.  Other  things  being 
equal,  the  rapidity  of  this  healing  process  is  directly  proportional  to 
the  degree  of  separation  of  the  edges  of  the  original  wound.  For 
instance,  small  and  incised,  as  well  as  some  punctured  wounds  which 
have  not  been  exposed  to  septic  or  other  irritating  or  disturbing  influ- 
ences, may  heal  in  the  course  of  twenty-four  hours.  In  general,  how- 
ever, from  five  to  seven  days  are  required  before  the  completion  of  the 
healing  process,  as  announced  by  the  falling  off  of  the  scab,  occurs. 

Similarly,  in  the  skin  very  considerable  losses  of  substance,  particu- 


90  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

* 

larly  if  these  extend  only  to  the  rete  Malpighii,  may  undergo  com- 
plete repair  in  a  very  short  time.  Here  the  hemorrhage  being  very 
slight,  rapid  drying  of  the  effused  blood  takes  place,  and  under  the 
protection  of  the  crust  thus  formed  complete  cicatrization  soon  follows. 
Very  different,  however,  is  the  process  in  a  widely  gaping  wound  if 
nature  is  left  unaided  or  disturbing  influences  enter.  Rapid  drying  is 
prevented  by  the  extent  of  the  injury  and  the  size  of  the  coagulum, 
as  well  as  by  the  presence  of  a  large  quantity  of  lymph  which  oozes 
from  the  spaces  which  have  been  opened.  Here  the  conditions  favor- 
able for  the  implantation  and  reproduction  of  septic  organisms  are 
present.  These  include,  first,  the  presence  of  organic  tissues  deprived 
of  their  protecting  cuticle  and  with  their  vital  resistance  otherwise 
lessened  by  the  infliction  of  an  injury;  second,  a  favorable  temperature 
(blood-heat) ;  and  third,  moisture.  With  the  rapid  drying  of  the  sur- 
face of  the  coagulum  in  trivial  incised  wounds  the  septic  organisms 
are  deprived  of  that  moisture  which  is  essential  to  their  proliferation. 
In  the  case  of  large  gaping  wounds,  however,  this  desiccation  cannot 
take  place  readily,  invading  micro-organisms  rapidly  multiply  under 
the  favorable  conditions  present,  and  as  a  result  putrefaction  and  disor- 
ganization of  tissue  take  the  place  of  repair.  In  the  course  of  twenty- 
four  hours  the  wound-surfaces  become  covered  with  a  semi-liquid  and 
foul-smelling  layer  of  broken-down  tissue  swarming  with  the  bacteria 
of  putrefaction.  Following  this,  striking  and  peculiar  changes  take 
place  in  the  neighborhood  of  the  wound,  due  to  the  spread  of  infection 
from  the  original  site  of  proliferation  of  the  bacteria.  These  changes 
are  characterized  by  a  more  or  less  broad  zone  of  redness  which 
makes  its  appearance  about  the'wound-edges  together  with  increased 
heat  in  the  part  and,  finally,  by  increased  density,  or  induration  of  the 
surrounding  tissues.  At  the  same  time  the  patient  complains  of  pain 
and  a  feeling  of  tension  in  the  parts  involved  in  these  nutritive  disturb- 
ances. With  progressive  putrefaction  of  the  coagulum  these  symptoms 
increase.  Where  the  surrounding  parts  have  been  involved  in  the 
original  injury,  as  in  contused  wounds,  a  foul-smelling  semi-fluid  mass 
issues  from  beneath  the  wound-edges,  mingled  with  the  debris  of 
broken-down  tissue.  If  improvement  takes  place  a  yellowish-white 
secretion,  not  unlike  cream,  makes  its  appearance  upon  the  edges  of 
the  wound  and  in  its  depths.  This  is  the  "  laudable  pus  "  of  the  older 
surgeons,  and  makes  its  appearance  about  the  fifth  day.  Under 'favor- 
able conditions  and  with  the  measurable  return  of  the  quality  of  vital 
resistance  to  the  involved  tissues  the  ichorous  discharge  ceases,  and 
the  wound  enters   upon  the  stage  of  suppuration. 

In  the  stage  of  suppuration  the  classical  symptoms  of  an  inflam- 
matory process — namely,  redness,  heat,  pain,  and  swelling — diminish. 
The  time  covered  by  this  stage  of  the  process  of  healing  will  vary 
with  the  depth  of  the  wound,  the  extent  of  laceration  of  its  edges  and 
contusion  of  the  neighboring  tissues.  In  an  average  case  of  lacerated 
wound,  from  about  the  seventh  day  a  mass  of  material  of  a  pinkish  hue 
forms  beneath  the  layer  of  pus  and  is  observed  to  rise  from  the  depths 
of  the  wound.  This  mass,  which  is  made  up  of  small  papillae,  con- 
tinues to  rise  until  it  fills  in  the  entire  wound-cavity.  Its  surface 
presents  a  granular  appearance,  the  papillae  are  called  granulations, 


WOUNDS. 


91 


''•\ 


and  the  wound  is  said  to  have  entered  upon  the  stage  of  granulation 

(Fig-  30)- 

The  surrounding  parts  at  this  time  begin  to  assume  their  nor- 
mal condition.  With  the  dis- 
appearance of  redness  and 
heat,  tenderness  together  with 
some  slight  degree  of  indura- 
tion alone  remains.  The  per- 
sistence of  these  latter  indi- 
cates that  the  reparative  proc- 
ess is  still  going  on  in  the 
depths  of  the  wound.  In  the 
beginning  of  the  granulating- 
stage  of  the  healing  process 
the  granulations  become  more 
or  less  easily  injured  and  bleed 
upon  the  slightest  touch.  As 
the  body  of  the  wound  be- 
comes filled  with  granulation- 
tissue  the  latter  becomes,  to 
some  extent,  solidified,  loses 
its  bright-pink  color,  and  be- 
comes pale.  Coincidently  with 
these  changes  a  shrinking  pro- 
cess goes  on,  with  correspond- 
ing diminution  of  the  cavity  of 
the  wound. 

Finally,   when    the  granu- 
lating surface  reaches  the  level 
of  the  surrounding  skin,  a  nar- 
row strip  of  new  epidermis  be- 
gins to  growaround  the  wound- 
edges.     This  slowly  increases 
from    without    inward.       One    t 
concentrically    growing    zone    Fu;.  29. 
after  another  is  added  to  the 
new  tissue  until,  these  meeting  in  the  middle,  the  granulating  surface  is 
completely  covered,  and  cicatrization  is  accomplished. 

The  processes  described  are  what  are  known  as  healing  by  primary 
(Fig.  29)  and  secondary  intention.  Healing  by  first  intention  seems 
almost  a  physiological  process ;  it  is  the  simplest  and  most  direct 
method  of  repairing  lost  tissue,  and  is  quite  similar  to,  if  not  identical 
with,  normal  epithelial  metamorphosis.  In  the  second  method  of 
repair,  or  healing  by  second  intention,  tissue-reproduction  attended 
with  suppuration  is  marked  by  the  presence  of  inflammatory  conditions 
with  their  essential  and  characteristic  symptoms,  known  since  the  days 
of  Galen  as  redness  (rubor),  local  heat  (calor),  swelling  {tumor),  and  pain 
(dolor). 

Histological  Considerations. — It  was  formerly  supposed  that 
the  coagulum  formed  in  the  interspace  served  the  purpose  of  accom- 
plishing immediate  union  of  the  wound,  when  this  took  place.     It  is 


Abdominal  wound:  healing  by  first  inten- 
tion, tenth  day. 


92  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

now  known,  however,  that  direct  adhesion  of  the  histological  elements 
of  the  parts  and,  hence,  immediate  union  do  not  occur  without  further 
effort.  A  fine  network  made  up  by  trabecular  is  formed  in  the  exuded 
fibrin,  from  which  processes  pass  into  the  open  blood-vessels  and  into 
the  clefts  or  spaces  in  the  tissues. 

Blood-corpuscles  and  small  portions  of  necrotic  tissue  and  coagu- 
lated fibrin  are  formed  in  the  cavity  of  the  wound  itself.  Some  of  the 
blood-corpuscles  have  assumed  a  star-shaped  appearance,  while  others 
are  simply  swollen  and  pale  in  color.     Coagulation  in  the  neighboring 


Fig.  30. — Granulating  wound  on  the  surface  of  a  nodule. 

capillaries  follows  the  passage  of  the  trabecular  into  the  mouths  of  the 
open  blood-vessels.  The  last  traces  of  the  red  blood-corpuscles  have 
almost  entirely  disappeared  at  the  end  of  forty-eight  hours,  their  former 
site  being  marked  by  spaces  in  the  network.  Those  which  remain 
become  either  translucent  or  finely  granular. 

With  the  disappearance  of  the  red  blood-corpuscles  the  so-called 
cells  of  new  formation  make  their  appearance.  These  are  small  round 
cells  with  a  clear  nucleus,  and  resemble  the  young  cells  of  connective 
tissue  as  well  as  the  colorless  blood-corpuscles.  These  fill  up  the  gap 
and  are  crowded  into  the  surrounding  injured  structures  and  neighbor- 
ing perivascular  spaces.  About  the  fourth  day  blood-vessels  pass  in 
small  loops  from  the  edges  of  the  wound  and  meet  and  unite  in  the 
middle  of  the  intervening  coagulum  (Julian  Arnold).  These  vessels 
spring  from  the  capillaries  by  a  process  of  "budding,"  a  slight  granu- 
lar thickening  (protoplasmic  proliferation)  marking  the  site  upon  the 
wall  of  a  capillary  where  a  new  vessel  is  about  to  bud.  This  granular 
thickening  or  projection  develops  into  a  fine  cord  with  a  thread-like 
termination.  The  base  of  this  protoplasmic  cord  becomes  hollowed 
out  upon  the  side  toward  the  vessel  from  which  it  springs,  and  blood 
enters  the  cone-shaped  base  from  the  parent  vessel.  Arch-shaped 
connection  between  two  capillaries  is  established  by  union  of  these 
protoplasmic  cords,  and  the  protoplasmic  arch  is  thus  formed.  Finally, 
complete  communication   is   established  by   a  process   of  canalization 


WOUNDS. 


93 


which  takes  place  in  the  intermediate  portion  of  the  arch.  The  proto- 
plasmic arches  become  lined  with  endothelium. 

By  a  process  of  cleavage  new  cellular  elements  develop,  new  cap- 
illary vessels  are  formed,  and  this  primary  cellular  layer  is  enlarged 
from  within  by  the  adjacent  round  cells  of  new-formation,  which 
form  the  adventitia  of  the  new  vessels.  These  formative  round  cells 
of  Marchand  fill  the  wound  and  soon  begin  to  undergo  transformation. 
A  framework  springs  up  in  the  spaces  between  the  cells,  which,  in  all 
probability,  originates  in  the  cells  themselves.  This  framework  is  partly 
striped  and  partly  granular  at  first,  but  later  in  the  development  the 
striped  appearance  becomes  more  clearly  defined,  and  there  eventually 
develop  in  the  intercellular  substance  fine  fibers  at  the  site  of  the  for- 
mer striations.  Between  these  fine  fibers  are  found  spindle-cells,  which 
by  some  are  supposed  to  be  the  remains  of  the  formerly  existing  mass 
of  round  cells.  The  new  tissue  now  closely  resembles  young  connec- 
tive tissue ;  it  is  richer  in  blood-vessels,  however.  The  spindle-cells, 
as  well  as  the  round  or  formative  cells,  disappear  by  processes  of  granular 
degeneration  and  absorption,  or  they  are  either  taken  up  by  the  circu- 
lation when  only  partly  developed  or  destroyed  by  cell-action. 

Finally,  the  process  of  repair  is  completed  by  the  sheltering  cover 
of  the  epidermis.  Pending  the  formation  of  the  latter,  a  crust  of  broken- 
down  blood-corpuscles  and  epithelial  scales,  held  together  by  dried 
exudation,  forms.  Beneath  this  temporary  protection  new  epithelium, 
furnished  by  the  rete  Malpighii  of  the  adjoining  skin,  develops.  Nuclear 
segmentation  of  the  cells  of  the  latter  takes  place,  and  these  new  cells 
arrange  themselves  from  the  periphery  over  the  surface  of  the  new- 
formation  until  they  meet  in  the  center,  and  the  surface  of  the  wound 
is  finally  covered  in. 

The  histological  processes  followed  in  the  healing  of  a  wound  by 
second  intention,  or  healing  by  suppuration,  are  essentially  the  same. 
When  the  round  cells  appear  and  are  brought  in  contact  with  the  pu- 
trid blood,  they  rapidly  perish  and  are  cast  off  with  the  secretions  of 
the  wound.  The  latter  consist,  at  this  time  (during  the  first  three  days), 
of  portions  of  fibrin,  red  blood-corpuscles  in  different  stages  of  decom- 
position, granular  detritus,  bacteria,  and  dead  connective-tissue  cells. 
These  cells  are  undergoing  changes  in  quality  and  form,  and  constitute 
with  the  leukocytes  which  migrate  to  the  parts  the  principal  components 
of  pus.  While  numerous  connective-tissue  cells  are  being  thrown  off 
from  the  surface  of  the  wound,  new  ones  are  being  supplied  to  take 
their  place,  until  the  lowest  layer,  becoming  gradually  supplied  with 
blood-vessels,  remains  to  form  the  young  connective  tissue,  which  latter, 
with  its  numerous  loops  of  vessels,  each  surrounded  by  a  growth  of 
the  same  connective-tissue  cells,  appears  as  a  collection  of  bright  and 
irregular  nodules,  the  granulations.  With  lessened  discharge  of  pus 
the  granulation-tissue  gradually  fills  up  the  cavity,  and  the  size  of  the 
latter  is  diminished  by  a  general  shrinkage  of  the  whole  wall.  Finally, 
as  the  surface  of  the  wound  becomes  level  with  the  surrounding  sur- 
face, cicatrization  is  completed  by  the  renewal  of  the  protective  epider- 
mis. While,  as  a  rule,  the  new  epidermis  forms  a  narrow  zone  about 
the  edges  of  the  wound,  it  occasionally  happens,  in  addition,  that  little 
islets  spring  up  away  from  the  margin,  themselves  to  become  the  cen- 


94  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

ters  of  successive  zones  of  new  epidermis.  Inasmuch  as  these  cannot 
spring  from  the  rete  Malpighii,  the  explanation  of  their  occurrence  is 
that  they  either  originate  from  the  cells  surrounding  the  sweat-glands 
and  hair-follicles  which  may  have  escaped  injury,  or  are  the  offspring 
of  epithelial  cellular  elements  that  have  been  accidentally  engrafted 
upon  the  granulating  surfaces  during  changes  of  dressings,  or  in  some 
other  way.  In  any  event,  it  is  not  probable  that  these  epithelial  cells 
are  formed  from  the  round  cells  of  the  granulating  tissue. 

The  question  of  the  origin  of  the  connective-tissue  cells  during  the  healing  process  has 
received  a  great  deal  of  attention.  It  was  formerly  supposed  that  the  spindle-shaped  cor- 
puscles, the  only  cells  then  known  to  exist  as  connective  tissue  cells,  were  the  progenitors 
of  the  round  cells.  The  origin  of  this  belief  was  probably  the  observation  previously  made 
that  in  fetal  connective  tissue,  spindle-cells  developed  from  the  round  cells  are  found  lying 
in  numbers  in  the  matrix  (  Yirchow).  Recklinghausen  in  1S63,  in  the  course  of  experiments 
on  the  cornea  of  rabbits  and  frogs,  found  in  addition  to  the  so-called  fixed  corneal  corpuscles 
small  round  cells  which  possessed  the  peculiar  property  of  changing  their  form  and  position 
in  a  manner  entirely  independent  of  each  other.  They  bore  a  striking  resemblance  to  the 
pus-cells  as  well  as  the  white  blood-corpuscles.  This  aroused  inquiry  which  finally  resulted 
in  Cohnheim's  successful  demonstration  of  the  direct  origin  of  the  migratory  cells  from  the 
blood  and  the  identification  of  these  with  the  white  blood-corpuscles  (1867),  although  as 
long  ago  as  1824  Dubachet  in  France,  and  again  in  1846  Waller  in  England,  discovered  the 
emigration  of  the  white  blood-corpuscles  through  the  walls  of  the  vessels  in  the  mesentery 
of  the  frog  without,  however,  realizing  the  importance  of  the  subject.  Whether  all  the  pus 
present  in  a  case  of  prolonged  suppuration  can  be  accounted  for  by  Cohnheim's  theory  is  an 
interesting  question.  It  is  difficult  to  understand  how  the  blood  could  furnish  such  enormous 
quantities  of  colorless  blood-corpuscles.  According  to  the  Cohnheim  diapedesis  theory,  not 
only  must  the  blood  furnish  the  enormous  amount  of  pus  through  its  white  blood-corpuscles, 
but  in  addition  the  round  cells,  the  newly  formed  blood-vessels,  their  walls  (first  homoge- 
neous and  then  nucleated),  the  young  connective  tissue,  and  finally  the  granulation-structure, 
must  be  accounted  for.  In  opposition  to  this  the  adversaries  of  the  exclusive  diapedesis 
theory,  notably  Recklinghausen  and  Strieker,  reported  a  series  of  observations  wherein  it 
was  sought  to  show  that  connective-tissue  corpuscles,  as  well  as  endothelial  cells,  undergo  a 
contractile  change  of  shape  and  division.  This  was  combated  by  Cohnheim  and  his  follow- 
ers by  means  of  the  classical  experiments  with  cinnabar.  In  order  to  distinguish  the  white 
blood-corpuscles  from  other  cell-elements  for  which  they  might  be  mistaken,  the  blood  of 
frogs  was  injected  with  cinnabar,  the  finely  divided  particles  of  which  were  absorbed  by 
the  white  blood-corpuscles.  The  frogs  were  then  subjected  to  an  injury,  at  the  site  of 
which  the  white  blood-corpuscles  could  be  seen  escaping,  enclosing  the  particles  of  cinnabar. 
This  was  met  by  Recklinghausen  by  calling  attention  to  the  well-known  fact  that  the  parti- 
cles of  cinnabar  may  escape  directly  into  the  tissues  from  the  blood-vessels  of  frogs  so 
injected,  and  there  stain  cells  formed  outside  the  vessels.  At  the  present  time,  however, 
the  theory  of  extravascular  formation  of  cells,  although  it  constitutes  the  most  rational  ex- 
planation of  the  reparative  and  regenerative  processes  which  take  place  after  destruction  of 
parts,  has  not  been  established  by  direct  observation.  On  the  other  hand,  it  may  be  said 
that,  while  the  theory  of  migration  of  the  colorless  blood-corpuscles  appears  to  be  estab- 
lished, the  proof  that  these  lake  an  active  part  in  the  restoration  of  lost  parts  is  wanting. 
The  controversy  as  to  the  formation  of  the  cicatrix  through  the  medium  of  the  round  cells, 
whatever  the  origin  of  the  latter,  cannot  in  all  probability  be  settled  until  means  of  distin- 
guishing between  young  connective  cells  and  colorless  blood-corpuscles  have  been  dis- 
covered. 

The  distinction  between  healing  with  and  without  inflammation,  as 
heretofore  made,  must  be  abandoned.  Furthermore,  Galen's  definition 
of  the  conditions  present  must  be  broadened.  Experimental  research 
on  animals  and  observations  in  man  have  thus  far  determined  that  the 
local  disturbances  following  an  injury  to  the  tissues  are  essentially 
those  of  the  inflammatory  process,  including  as  they  do,  (1)  dilatation 
of  blood-vessels  ;  (2)  increase  in  the  permeability  of  their  walls  ;  (3) 
augmented  supply  of  nutriment  to  the  tissues ;  (4)  migration  of  white 
blood-corpuscles  through  the  vascular  walls  into  the  surrounding  con- 
nective-tissue  spaces.     In    an    advanced    stage    of  the    process    there 


.  wounds.  95 

probably  occurs  (5)  proliferation  of  pre-existing  cells  ;  and  under  cer- 
tain circumstances  there  occur  (6)  processes  of  degeneration  and  de- 
composition, resulting  in  more  or  less  loss  of  tissue. 

The  Treatment  of  Wounds  and  Contusions. — In  the  formal 
consideration  of  the  subject  of  the  treatment  of  wounds  and  contusions, 
following  the  division  of  the  subject  already  laid  down,  it  will  be  con- 
venient to  deal,  first,  with  injuries  which  involve  a  breach  of  continuity 
of  the  surface,  whether  of  skin  or  mucous  membrane,  and  to  which  the 
general  term  "  wound "  is  applied,  and  secondly,  with  subcutaneous 
injuries. 

The  underlying  principle  to  be  observed  in  the  treatment  of  all 
cases  of  injury  may  be  summed  in  the  word  "rest."  If  the  patient 
escapes  immediate  death  there  is  reason  to  hope  that  the  natural  proc- 
esses of  tissue-building  embraced  in  the  term  "repair"  will  be  suf- 
ficient, providing  these  are  permitted  to  go  on  in  an  uninterrupted 
manner,  to  restore  the  patient  to  comparative  or  even  perfect  health. 
In  addition  to  this,  arrest  of  hemorrhage  in  wounds,  and  in  some 
instances  of  subcutaneous  and  internal  injuries  as  well,  will  be 
demanded. 

The  methods  of  securing  the  most  perfect  rest  of  the  injured  parts 
will  vary  with  the  character  of  the  injury,  the  special  qualities  of  the 
tissues  involved,  the  location  and  conformation  of  the  injured  parts, 
natural  tendencies  to  displacement  of  separated  structures,  etc.  These 
matters  will  be  more  fully  discussed  in  the  chapters  devoted  to  the 
surgeiy  of  separate  regions.  In  the  present  connection  the  subject  of 
the  general  principles  involved  in  the  treatment  of  injuries  to  individual 
structures  will  alone  be  considered. 

Arrest  of  Hemorrhage. — Complete  hemostasis  is  to  be  obtained 
in  every  wound.  To  this  rule  there  is  but  one  exception — namely,  a 
wound  in  which  the  defect  caused  by  loss  of  tissue  is  to  be  filled  by 
an  attempt  at  so-called  organization  of  a  blood-clot.  In  small  wounds 
and  in  those  in  which  only  the  smallest  vessels  are  divided,  as  well  as 
in  wounds  involving  cartilaginous  and  fibrous  structures,  hemostasis 
may.  be  spontcuieous.  In  slightly  larger  wounds  bleeding  may  be 
arrested  by  mere  exposure  to  the  air.  The  majority  of  wounds 
coming  under  the  care  of  the  surgeon  require  artificial  methods  of 
hemostasis.  All  of  these,  as  well  as  the  natural  means  employed, 
act,  when  efficient,  by  producing  a  mechanical  obstruction  to  the  flow 
of  blood  from  the  divided  vessel,  this  obstruction  lasting  for  a  sufficient 
time  to  ensure  permanent  sealing  of  the  divided  vessel-end. 

First  among  methods  of  arresting  hemorrhage  is  pressure.  This 
may  be  digital,  the  finger  being  placed  upon  the  bleeding  point,  either 
distad  or  proximad  to  the  same.  This,  as  a  rule,  is  a  temporary  expe- 
dient only,  and  when  placed  upon  the  cut  end  of  the  bleeding  vessel 
the  finger  in  the  wound  is  in  the  way  of  the  manipulation  necessary  in 
subsequent  treatment.  It  is  objectionable  also  in  other  respects — i.  c, 
it  increases  the  risks  of  suppuration  by  favoring  the  introduction  of 
septic  material  into  the  depths  of  the  wound,  as  well  as  by  producing 
increased  traumatism  of  the  parts  involved  in  the  injury,  and  thus 
emphasizing  the  locus  minoris  rcsistcutic?.  Hence  digital  compression 
is  to  be  classed  as  a  temporary  expedient,  to  be  used  only  in  cases  in 


g6  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

which  an  unnecessarily  large  amount  of  blood  will  be  lost  before  other 
and  better  methods  can  be  applied.  As  an  example  of  such  cases 
may  be  mentioned  extensive  wounds  of  the  forearm  involving  the 
radial  and  ulnar  arteries,  when  pressure  of  the  brachial  will  arrest  the 
hemorrhage;  or  again  in  operations  upon  the  kidney  in  which  the 
renal  artery  and  vein  have  been  wounded  with  the  organ  still  in  situ, 
and  in  which  it  would  be  unwise  to  attempt  to  employ  a  forceps  at 
once,  when  a  thumb  and  finger  introduced  into  the  depths  of  the 
wound  will  so  much  more  readily  and  quickly  grasp  the  pedicle  and 
arrest  the  hemorrhage,  and  will  serve  also  as  a  guide  for  the  applica- 
tion of  the  forceps. 

Compression  by  means  of  sponges  or  compresses  is  far  superior  to 
the  digital  method,  as  the  pressure  may  be  exerted  over  large  or  small 
areas  at  will  and,  besides,  is  more  even,  thus  interfering  less  with  the 
local  nutrition  of  the  part  than  digital  pressure.  This  means  of  hemo- 
stasis  is  particularly  applicable  to  wounds  involving  large  areas  of 
wounded  arterioles  and  venules.  Heat  is  advantageously  used  in 
connection  with  gauze  compresses.  This  may  be  dry  heat,  applied 
through  the  medium  of  towels  direct  from  the  sterilizer  and  laid  upon 
the  wound-surface  either  with  or  without  compression,  and  of  a  tem- 
perature almost  unbearable  to  the  operator's  hand.  The  hot  gauze  or 
towel  -should  be  covered  with  other  towels,  so  that  the  effect  may  be 
continued  as  long  as  possible  without  the  necessity  of  renewal.  Just 
previous  to  the  application  the  wound-surfaces  should  be  carefully 
dried.  This  application  of  heat  likewise  serves  to  counteract  whatever 
shock  is  present.  One  towel  or  a  succession  of  towels  may  be  used. 
Moist  heat  may  be  applied  by  means  of  towels  wrung  out  of  very 
hot  plain  water  or  a  0.6  per  cent,  salt-solution  in  the  case  of  non- 
infected  wounds,  or  some  antiseptic  solution  in  the  case  of  wounds 
suspected  of  sepsis.  Cold,  on  the  other  hand,  while  a  useful  hemo- 
static agent  under  some  circumstances,  is  not  to  be  used  directly  on 
a  wound-surface,  for  the  reason  that  it  devitalizes  the  tissues  to  too 
great  an  extent. 

Of  chemical  means  for  the  arrest  of  hemorrhage  in  the  treatment 
of  wounds,  the  less  said  the  better.  They  have  no  place  in  the  arma- 
mentarium of  the  well-equipped  surgeon.  They  do  more  harm  than 
good,  and,  whether  the  wound  be  non-infected  or  septic,  chemical 
agents  in  wound-treatment  for  the  arrest  of  hemorrhage  are  abso- 
lutely and  unreservedly  contraindicated.  Even  should  they  accom- 
plish their  object,  they  do  this  by  an  unnecessary  destruction  of  tissue, 
thus  increasing  the  wound-area ;  they  lead  to  increased  exudation,  pre- 
dispose to  secondary  hemorrhage,  inflict  unnecessary  traumatism  upon 
adjacent  structures,  still  further  lowering  the  vital  resistance  and  ren- 
dering impossible  primary  union  or  any  approach  to  it,  and  in  every 
way  delay  rapid  healing.  They  are  inefficient  in  the  face  of  active 
hemorrhage,  and  in  wounds  the  bleeding  from  which  is  of  a  minor 
character,  other  and  better  means  are  always  within   reach. 

Last  but  best  of  the  many  means  at  our  disposal  in  the  arrest  of 
hemorrhage  from  wound-surfaces  is  the  application  of  the  hemostatic 
foireps.  It  accomplishes  the  end  either  by  pressure  alone  or  by  press- 
ure combined  with  torsion.    Should  this  means  prove  unsuccessful,  the 


WOUNDS.  97 

application  of  the  ligature  is  at  once  efficient  and  trustworthy.  The 
degree  of  traumatism  inflicted  is  slight  if  the  proper  instrument  and 
approved  method  of  application  are  employed ;  the  result  is  immediate 
and  satisfactory. 

Cleansing  and  Disinfection — Preliminary  cleansing  of  the  wound 
and  its  surroundings  constitutes  the  difference  between  operative  and 
accidental  wound-treatment.  It  is  the  lack  of  this  that  renders  the 
latter  difficult  of  management.  The  treatment  of  all  non-operative 
wounds  is  essentially  the  same,  the  object  being  to  cleanse  thor- 
oughly, first  the  surroundings,  and  second  the  wound  itself,  so  that  the 
latter  will  conform  as  nearly  as  possible  to  a  properly  treated  opera- 
tion-wound. While  aseptic  wound-treatment  is  mainly  applicable  to 
wounds  made  by  the  surgeon,  the  latter  will  occasionally  be  sum- 
moned sufficiently  early  to  an  accidentally  inflicted  wound  or  to  those 
made  under  circumstances  which  impel  him  to  consider  the  wound  not 
materially  infected,  in  which  case  the  aseptic  treatment  may  be  insti- 
tuted. In  any  event  methods  must  be  employed  which  will,  as  far  as 
possible,  sterilize  the  site  of  the  wound,  its  immediate  neighborhood, 
and  all  articles  that  are  likely  to  come  in  contact  with  it,  including  the 
hands  and  persons  of  the  surgeon  and  his  assistants.  A  large  propor- 
tion of  the  pathogenic  bacteria  which  finally  find  their  way  into  wounds 
have  their  habitat  upon  the  cutaneous  surface  of  the  body  or  in  those 
articles  of  wearing  apparel  worn  next  to  the  skin.  Others  less  virulent, 
but  capable  of  becoming  actively  pathogenic  under  conditions  of  les- 
sened local  vital  resistance,  such  as  the  Staphylococcus  epidermidis  albus 
(Welch),  are  also  present,  as  well  as  others  that  are  positively  harmless. 
Only  criminal  carelessness  will  permit  a  surgeon  to  make  an  incision 
into  integument  which  has  not  been  deprived,  as  far  as  possible,  of 
these  lurking  sources  of  danger.  No  disinfection  or  sterilization  of 
instruments,  care  in  operative  technic,  nor  application  of  antiseptic 
dressings  can  in  any  degree  compensate  for  failure  in  this  respect. 
(For  aseptic  operative  technic  see  Chapter  XI.) 

The  use  of  pure  carbolic  acid  in  the  disinfection  of  wounds  has 
recently  been  revived  by  Powel  and  Phelps,  upon  the  basis  oi  the 
antidotal  action  of  alcohol  to  carbolic  acid.  The  edges  of  the  wound 
are  to  be  protected  by  moistening  with  alcohol.  The  cavity  of  the 
wound  is  then  filled  with  pure  carbolic  acid,  and  irregularities  of 
the  former  reached  by  means  of  a  cotton  swab.  The  carbolic  acid  is 
permitted  to  remain  in  contact  with  the  tissues  for  the  space  of  one 
minute,  after  which  it  is  withdrawn  by  means  of  a  pipette,  and  the  fur- 
ther action  of  that  which  still  remains  in  contact  with  the  tissues  is 
neutralized  by  the  free  application  of  95  per  cent,  alcohol.  The  writer 
has  employed  this  method  in  infected  wounds,  as  well  as  in  infected 
cavities  following  the  removal  of  foci  of  osteomyelitis,  with  marked 
success. 

In  accidentally  inflicted  wounds  the  indications  for  preventing  further 
infection  are  as  imperative  in  their  demands  as  are  those  precautions 
taken  prior  to  the  infliction  of  an  operative  wound.  The  clothing  must 
be  removed  and  the  surface  of  the  body  in  the  neighborhood  subjected 
to  a  vigorous  scrubbing  with  warm  water  and  a  strongly  alkaline  soap, 
a  clean  bristle  hand-brush  being  employed  for  the  purpose.    The  parts 


98  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

are  then  to  be  shaved,  again  scrubbed,  washed  with  ether  and  alcohol, 
rinsed  with  a  I  :  iooo  sublimate  solution,  and  covered  with  a  gauze 
compress  wetted  with  the  latter,  pending  further  care  of  the  wound, 
such  as  the  introduction  of  sutures,  etc.  Further  precautions  against 
reinfection  consist  in  covering  the  surrounding  parts  with  sterilized 
towels. 

In  the  case  of  wounds  of  cavities  lined  with  mucous  membrane, 
special  cleansing  methods  are  to  be  followed.  The  mouth  and  the 
pharyngeal  cavities  are  cleansed  with  a  I  per  cent,  solution  of  potassium 
chlorate  or  a  wine-colored  solution  of  potassium  permanganate.  The 
teeth  are  to  be  vigorously  brushed  with  a  stiff  tooth-brush.  Carious 
teeth  should  be  removed.  The  vagina  should  be  cleansed  with  soap 
and  warm  water,  a  bunch  of  gauze  or  absorbent  cotton  grasped  in  a 
sponge-holder  or  forceps  being  used  to  assist  in  the  cleansing.  In 
wounds  involving  the  rectum  the  latter  is  to  be  emptied  and  irrigated, 
and  its  upper  part  packed  off  with  bunches  of  gauze  coated  with  vas- 
elin  while  the  sutures  are  being  applied.  Threads  are  attached  to  the 
gauze  to  facilitate  its  removal.  The  bowels  are  confined  for  two  or 
three  days,  and  when  finally  moved  the  stools  are  rendered  fluid  by 
proper  laxative  medication  and  enemata  to  prevent  separation  of  the 
suture-line. 

In  the  treatment  of  accidental  wounds  the  cleansing  of  the  wound 
itself  consists  in  the  removal  of  all  foreign  material,  the  presence  of 
which  must  necessarily  interfere  with  repair.  Blood-clots  are  removed, 
as  well  as  all  macroscopic  dirt.  Cases  coming  under  the  care  of  the 
surgeon  after  necrotic  changes  have  occurred  demand  the  removal  of 
all  dead  or  dying  tissues,  as  far  as  possible.  The  removal  of  the  latter, 
unless  demanded  at  once  by  grave  general  sepsis,  may  be  left  to  na- 
ture's efforts,  but  may  be  greatly  facilitated  by  the  employment  of  an 
agent  that  shall  combine  antiseptic  and  stimulating  properties,  such  as 
naphthalin,  the  rapidly  forming  granulations  tending  to  throw  off  the 
devitalized  parts.  Other  foreign  material,  such  as  bits  of  glass,  steel, 
buttons,  portions  of  clothing,  small  fragments  of  bone,  etc.,  must  be 
removed  by  means  of  pieces  of  gauze,  thumb-forceps,  and  irrigation. 
Instruments  especially  designed  for  the  purpose,  such,  for  instance,  as 
bullet-forceps,  are  employed  in  suitable  cases,  and,  in  addition,  the  use 
of  the  knife,  scissors,  and  curet  becomes  necessary  under  certain  cir- 
cumstances. As  a  cutting  instrument  for  enlarging  wounds  in  order  to 
gain  better  access  to  foreign  bodies,  the  knife  is  to  be  preferred  to  the 
scissors,  for  the  reason  that  the  latter  divides  the  structures  with  a 
crushing  effect,  and  hence  inflicts  an  additional  degree  of  traumatism. 
The  curet  is  mainly  useful  in  the  removal  of  septic  granulation-tissue 
in  the  course  of  the  after-treatment.  Gitnpozvder  grains  may  be  re- 
moved in  great  part  by  a  vigorous  scrubbing  with  a  stiff  brush  under 
an  anesthetic  and  subsequent  removal  of  the  remaining  grains  by  a 
fine-pointed  knife  and  delicate  forceps.  Even  if  each  grain  is  not  re- 
moved in  this  way  in  its  entirety,  it  is  broken  up  into  fine  particles  which 
finally  disappear  in  the  majority  of  cases,  leaving  but  little  staining  of 
the  tissues. 

Contused  Wounds — It  is  always  to  be  borne  in  mind  that  rapid 
union  and  sjood  functional  result  are  to  be  desired   in  all  wounds  how- 


wounds.  99 

ever  contused  or  lacerated,  and  to  this  end  every  other  consideration 
is  to  be  subservient.  In  former  times  it  was  considered  useless  to  at- 
tempt to  obtain  primary  union  in  cases  where  the  wound-edges  were 
contused.-  The  existence  of  this  condition,  indeed,  was  considered  a 
contraindication  to  the  closure  of  the  wound,  violent  phlegmonous 
inflammatory  action  frequently  ensuing.  The  reasons  for  the  occurrence 
of  the  latter  are  now  well  known.  What  with  the  introduction  of 
irritating  micro-organisms  at  the  time  of  the  reception  of  the  injury, 
the  lessening  of  the  vital  resistance  of  the  involved  tissues  by  the  latter, 
and,  in  addition,  the  possibilities  of  further  infection  through  the  me- 
dium of  the  suture-material  or  other  means  employed  to  close  the 
wound,  in  the  light  of  our  present  knowledge  the  only  wonder  is  that 
the  patients  escaped  with  their  lives,  not  that  their  wounds  should 
have  healed.  Immediate  union  of  wounds  with  contused  edges  is  now 
attempted  under  circumstances  where  the  requirements  of  a  rigid 
asepsis  and  antisepsis  are  met.  Cases  will  arise,  however,  in  which  the 
tissues  are  crushed  beyond  hope  of  recovery.  Here  either  the  attempt 
to  obtain  primary  union  must  be  abandoned,  or  the  crushed  portions 
must  first  be  removed. 

Coaptation — This  consists  in  replacing  the  severed  tissues  in  as 
nearly  their  normal  relation  as  possible.  This  is  easily  accomplished 
in  the  case  of  incised  wounds,  but  in  contused  and  lacerated  wounds  it 
is  difficult,  and  when  there  is  considerable  loss  of  tissue,  impossible. 
It  should  be  attempted  in  all  wounds  that  will  permit  it.  It  may 
be  immediate,  or  directly  following  proper  hemostasis  and  cleans- 
ing and  disinfection,  or  secondary,  some  hours  or  even  days  inter- 
vening, as  in  cases  in  which,  from  the  nature  of  the  wound,  a  copious 
discharge  is  expected  to  occur.  Position  ranks  first  in  securing  coapta- 
tion. The  wounded  part  is  to  be  brought  into  such  a  position  as  to 
diminish  to  the  greatest  possible  extent  the  tendency  of  its  edges  to 
gape.  This  may  be  attained  by  either  flexing  or  extending  the  parts, 
according  to  circumstances.  Bandages,  fixed  dressings  such  as  those 
of  plaster  of  Paris,  and  splints  of  various  kinds  are  used  to  insure 
maintenance  of  the  proper  position.  Pressure  may  be  employed  in 
suitable  cases,  as  in  small  wounds  whose  edges  show  very  slight  ten- 
dency to  gape,  or  indirect  by  means  of  rolls  of  gauze  placed  on  each 
side  of  the  wound  and  held  in  place  by  a  retaining  dressing.  Adhesive 
material  is  sometimes  used,  such  as  adhesive  plaster,  collodion,  plain 
or  incorporated  in  gauze  or  absorbent  cotton.  It  is  only  in  small  or 
superficial  wounds  that  adhesive  material  is  of  service,  and  then  only 
when  asepsis  is  reasonably  well  assured.  In  large  wounds  it  is  used  as 
an  adjunct  to  other  measures.  Collodion  is  particularly  useful  in  draw- 
ing together  the  suture-line,  while  adhesive  plaster  is  useful  applied 
outside  the  dressing  as  an  adjunct  to  the  binder  or  bandage,  especially 
in  such  parts  as  the  chest  or  abdomen,  where  absolute  rest  is  most  es- 
sential and  at  the  same  time  difficult  to  obtain. 

Sutures  rank  next  in  importance  to  position  and  rest  in  maintaining 
the  parts  in  their  relation  to  each  other.  The  strength  and  durability 
of  the  material  employed  will  depend  upon  the  character  of  the  tissues 
to  be  approximated,  their  situation,  etc.  In  suturing  the  integumentary 
tissues  the  materials  selected  should  be  such  as  are  least  favorable  to 


IOO  1XTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

germ-growth.  For  this  reason  catgut  should  be  discarded,  and  silk- 
worm-gut, silver  wire,  or  silk  used.  For  those  deeper  structures  which 
take  long  in  healing,  such  as  bone,  tendon,  and  fascial  and  aponeurotic 
tissues,  stouter  and  more  resistant  material  will  be  required  than  in  the 
case  of  muscles,  nerves,  and  blood-vessels,  which  unite  more  rapidly. 
According  to  J.  B.  Murphy,  however,  silk  is  the  preferable  material  in 
suturing  wounds  of  blood-vessels.  The  traumatism  inflicted  by  the 
sutures  themselves  should  be  borne  in  mind,  and  the  size  and  character 
of  the  material  should  be  selected  with  this  in  view.  Severed  nerves, 
muscles,  tendons,  bones,  fasciae  and  aponeuroses,  and  the  larger  blood- 
vessels should  be  approximated  each  with  its  appropriate  suture.  In 
superficial  wounds  imperatively  requiring  suturing,  such,  for  instance,  as 
those  located  over  the  point  of  the  elbow,  the  knee,  and  of  the  scalp, 
and  which  tend  to  gape  widely,  skin-sutures  alone  are  sufficient.  In 
deeper  wounds  sutures  may  approximate  the  wound-layers  separately 
or  all  may  be  included  in  one  layer,  these  being  either  buried  or  re- 
movable. In  bringing  the  sutures  through  the  skin  they  may  be  made 
to  emerge  near  the  wound-edges  or  at  a  distance  from  them.  The 
latter  are  known  as  "  relaxation-sutures,"  since  they  transfer  the  strain 
of  the  stitches  from  the  immediate  neighborhood  to  a  distance.  Tension 
upon  the  wound-edges  should  be  avoided  whenever  possible,  since,  as 
a  result  of  the  traumatism,  these  possess  a  lower  vitality  than  the  parts 
at  a  distance,  and  hence  are  more  liable  to  become  infected.  The  ten- 
sion of  the  suture  may  be  overcome  in  great  measure  by  correct  posi- 
tion and  relaxation-sutures  ;  that  arising  from  compression,  if  it  result 
in  necrosis  of  tissue,  is  inexcusable.  In  addition  to  necrosis  and  infec- 
tion following  the  improper  application  of  sutures,  the  strain  placed 
upon  structures  sutured,  particularly  in  the  case  of  large  defects  in 
tissues  naturally  unyielding,  may  be  excessive  in  spite  of  every  care 
upon  the  part  of  the  surgeon.  It  may  even  prove  to  be  more  than  the 
structures  can  bear,  in  which  case  a  cutting  through  of  the  tissues  from 
ulcerative  action  occurs.  The  tissues  drag  against  the  rigid  and  un- 
yielding thread,  separation  occurs  in  the  suture-line,  and  the  thread 
often  becomes  buried  out  of  sight.  This  last  effect  sometimes  results 
from  undue  swelling  of  the  skin  itself  on  account  of  infection  from  too 
great  tension  upon  the  sutures,  the  result  of  overanxiety  on  the  part 
of  the  surgeon  to  secure  firm  approximation  of  the  wound-edges.  In 
this  connection  it  should  be  borne  in  mind  that  all  the  purposes  of 
coaptation  are  fulfilled  by  a  loose  adjustment  of  the  cut  edges  to  each 
other.  The  attempt  to  do  more  than  this  and  to  force  the  injured 
parts  firmly  against  each  other  will  accomplish  no  more  than  simple 
approximation,  and  is  fraught  with  risk. 

Drainage. — By  drainage  is  meant  the  process  of  removal  of  the 
wound-secretions.  Every  wound,  however  small,  is  the  seat  of  a  cer- 
tain amount  of  exudation.  In  the  early  stages  this  is  serious,  but  in 
the  event  of  infection  it  becomes  seropurulent  and  finally  purulent. 
The  indications  for  drainage  vary  in  different  wounds,  and  the  methods 
of  drainage  to  be  employed  are  governed  by  the  character  of  the  dis- 
charge. Small  incised  wounds  require  no  artificial  drainage ;  if  clean 
they  may  be  closed,  and  if  septic  they  may  be  left  open  for  natural 
drainage.       Large    incised    wounds    of    accidental    origin,    if    treated 


WOUNDS.  IOI 

promptly,  may  frequently  be  closed  without  drainage.  If  the  deeper 
fascial  and  aponeurotic  structures  have  been  opened  up,  and  there  is 
invasion  of  muscular  planes,  and  particularly  if  entrance  into  joints 
has  been  effected,  artificial  drainage  must  be  provided  for.  Wounds 
not  necessarily  extensive  in  themselves,  but  complicated  by  injuries  to 
the  surrounding  soft  parts  and  likely  to  give  rise  to  a  large  serous  exu- 
dation, may  be  left  entirely  open  for  the  first  twenty-four  or  forty-eight  - 
hours  and  lightly  tamponed  with  sterile  or  antiseptic  gauze.  Secondary 
suturing  may  be  practised  in  these  cases.  If  decided  infection  has 
taken  place  the  secondary  suture  must  be  postponed  until  all  traces  of 
this  have  subsided  ;  otherwise,  sutures  having  been  introduced  and  left 
loose  at  the  time  of  the  first  dressing,  the  wound  may  be  closed.  This 
method  of  primary  drainage  and  secondary  suture  has  much  to  recom- 
mend it  in  large  non-operative  wounds.  In  this  manner  speedy  union 
may  be  secured  in  wounds  in  which,  if  sutured  primarily,  tissue-necro- 
sis would  have  ensued  as  a  result  of  pressure  on  the  tissues  by  the 
suture,  the  cause  of  the  pressure  being  the  retention  of  the  wound- 
discharges.  Large  incised  wounds  without  coincident  damage  to  sur- 
rounding tissues,  even  though  sufficient  time  has  elapsed  and  the  sur- 
roundings are  such  as  to  excite  a  reasonable  suspicion  of  the  super- 
vention of  sepsis,  may  often  be  partially  closed  by  sutures,  the  most 
dependent  portion  being  left  open  for  natural  drainage,  or  artificial 
drainage  being  provided  for.  All  lacerated  and  contused  wounds  must 
be  drained  except  in  cases  where  the  contused  and  lacerated  portions 
can  be  removed  and  the  wound  converted  into  a  simple  incised  wound. 
This  should  be  done  whenever  possible;  but  where  it  cannot  be  accom- 
plished without  impairment  of  function  or  too  great  loss  of  tissue,  it 
is  contraindicated. 

All  wounds  of  non-operative  origin  must  be  carefully  watched. 
This  applies  with  special  emphasis  to  those  that  have  been  closed  pri- 
marily ;  these  are  to  be  opened  up  freely  upon  the  first  evidence  of 
sepsis.  The  border  line  between  aseptic  and  septic  wounds,  or  those 
likely  to  become  so,  is  difficult  at  times  to  determine  in  the  class  under 
discussion,  and  the  conservative  surgeon  will  take  the  safe  side  in  case 
of  doubt.  Given  a  wound  upon  a  portion  of  the  body,  particularly 
where  disfigurement  is  to  be  avoided,  as  in  the  case  of  the  face,  if  the 
circulatory  conditions  favor  rapid  healing  in  spite  of  some  exposure  to 
infection,  if  the  wound  has  been  seen  early  and  the  most  scrupulous 
precaution  taken  to  remove  any  possible  source  of  infection  from  the 
wound  and  its  neighborhood,  and  if  the  circumstances  surrounding  the 
infliction  of  the  wound  in  relation  to  sepsis  do  not  contraindicate, 
then  approximation  of  the  edges  should  be  accomplished  at  once.  If, 
on  the  other  hand,  considerable  time  has  elapsed  since  the  infliction  of 
the  wound,  the  latter  in  the  meantime  having  been  exposed  to  condi- 
tions inviting  sepsis,  as  contact  with  clothing  or  other  probable  sources 
of  infection,  if  the  surroundings  do  not  admit  of  disinfection  to  the 
satisfaction  of  the  surgeon,  and  if  upon  investigation  the  cause  of*  the 
wound  has  been  ascertained  to  involve  septic  conditions,  drainage  must 
be  employed.  In  deep  wounds  with  narrow  external  openings  and  in 
those  involving  joint-  or  other  cavities,  drainage  is  indicated.  In  large 
subcutaneous  injuries,  and  in  those  in  which  decided  losses  of  tissue 


102  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

cause  so-called  "  dead  spaces,"  counteropenings  are  indicated  to  allow 
of  sufficient  drainage. 

Means  of  Drainage. — -The  simplest  means  of  effecting  drainage  is 
leaving  open  the  most  dependent  part  of  the  wound,  the  so-called 
natural  drainage.  The  most  commonly  employed  means  of  artificial 
drainage  is  the  use  of  sterile  hygroscopic  gauze  or  cheese-cloth 
material.  It  is  indicated  in  wounds  with  serous  or  seropurulent  dis- 
charge, the  fluid  being  sufficiently  thin  to  permit  of  its  being  acted 
upon  by  the  capillarity  of  the  threads  of  the  gauze.  In  infected 
wounds  the  gauze  may  be  impregnated  with  some  antiseptic  agent, 
such  as  iodoform  or  zinc  oxid  ;  in  non-infected  wounds  plain  dry  sterile 
gauze  will  suffice.  Silkworm-gut,  horse-hair,  spun  glass,  and  narrow 
strips  of  oil-silk  or  rubber  tissue,  have  been  employed.  They  possess 
some  advantage  in  that  they  are  easier  of  removal.  A  perforated  cov- 
ering of  oil-silk  or  rubber  tissue  placed  upon  rolls  of  gauze  or  bundles 
of  common  lamp-wicking  assists  in  the  removal  of  the  drains  thus 
formed,  the  smooth  exterior  of  the  latter  facilitating  the  withdrawal. 
This  feature  is  a  particularly  desirable  one  in  the  removal  of  intraperi- 
toneal drains. 

In  wounds  from  which  the  discharges  are  too  profuse  or  too  thick  to 
be  acted  upon  by  capillary  action,  tube-drainage  is  employed.  Tube- 
drains  are  made  of  rubber,  glass,  silver,  and  decalcified  bone.  The  last- 
named  material  is  absorbable.  When  non-absorbable  tubes  are  em- 
ployed they  should  be  removed  as  soon  as  possible,  since  they  act 
as  a  foreign  body  to  a  greater  extent  than  does  simple  gauze.  The 
latter  should  replace  tube-drainage  at  the  earliest  possible  moment. 
Wounds  are  not  infrequently  maintained  in  a  septic  condition  by 
the  persistent  employment  of  tube-drainage,  for  granulation-tissue  of 
low  vital  resistance,  and  hence  easy  of  infection,  lines  the  fistulous 
track  along  which  the  tube  lies.  The  fistulous  tracks  are  some- 
times difficult  to  heal,  and  it  is  only  after  the  vigorous  use  of  the 
sinus-curet  to  remove  septic  granulation-material  that  closure  is  finally 
accomplished. 

Dressing  of  Wounds. — The  protection  of  the  line  of  coaptation  is 
of  importance.  The  soft  layers  of  cheese-cloth  now  so  universally 
employed  in  the  dressing  of  wounds  are  sufficiently  non-irritating  to 
be  brought  into  direct  contact  with  the  line  of  union  without  harm. 
Some  surgeons  prefer  a  narrow  strip  of  Lister's  oil-silk  protective, 
while  others  apply  a  layer  of  collodion  in  which  iodoform  or  some 
other  antiseptic  substance  has  been  dissolved.  These  are  unnecessary, 
save  under  the  exceptional  circumstances  of  wounds  in  localities 
where  it  is  almost  impossible  to  keep  the  gauze  dressings  closely 
applied  to  the  wound  and  its  surroundings.  In  view  of  the  fact  that 
any  additional  factor  entering  into  the  dressing  material  may  introduce 
sources  of  sepsis,  it  should  be  accepted  as  a  golden  precept  in  the  sur- 
gery of  wounds  that  whatever  is  unnecessary  may  be  mischievous  and 
had  better  be  omitted. 

In  addition  to  affording  protection  to  the  wound  against  infection 
and  injury,  dressings  are  designed  to  absorb  discharges  escaping  from 
the  wound.  They  are  applied  immediately  following  hemostasis,  cleans- 
ing and  disinfection,  coaptation  and  drainage.     The  hygroscopic  gauze 


WOUNDS.  103 

or  cheese-cloth  already  mentioned  serves  the  purpose  admirably,  and  is 
now  almost  universally  employed.  In  case  of  non-infected  wounds  the 
gauze  may  be  used  plain  ;  in  infected  wounds  it  must  be  impregnated 
with  some  antiseptic  substance.  In  cases  of  mild  infection  either  iodo- 
form or  zinc  oxid  answers  the  purpose  admirably  ;  in  most  virulent 
forms  of  infection  some  such  decidedly  germicidal  agent  as  corrosive 
sublimate  is  employed.  When  there  is  a  tendency  of  phlegmonous 
inflammation  to  spread,  saturating  the  dressings  with  a  2\  to  5  per 
cent,  carbolic-acid  solution  is  of  especial  service.  The  original  Lister 
dressing,  in  which  carbolic  acid  is  held  in  the  meshes  of  the  gauze  by 
some  resinous  material,  is  now  comparatively  little  used.  In  the  pres- 
ence of  evidences  of  infection,  and  particularly  where  sloughy  tissues 
are  to  be  separated,  wet  dressings  of  antiseptic  and  germicidal  solu- 
tions are  indicated ;  otherwise,  wounds  heal  more  rapidly  under  dry 
dressings. 

In  order  to  afford  sufficient  protection  to  the  wound  the  dressings 
should  be  applied  with  a  generous  hand,  and  should  cover  the  parts 
for  some  distance  from  the  wound  itself.  They  should  also  be  applied 
in  such  a  manner  as  to  offer  the  least  discomfort  to  the  patient  and 
afford  the  greatest  possible  rest  to  the  wounded  parts.  As  an  addi- 
tional protection  against  infection  from  the  atmospheric  air,  the  gauze 
dressings  are  covered  with  a  thick  layer  of  common  non-absorbent 
cotton  sterilized  by  dry  or  steam  heat.  This  is  not  the  finely  carded 
absorbent  cotton  of  the  dealers,  which  affords  little  or  no  protection 
against  germ-invasion.  Finally,  the  dressings  are  held  in  position  by 
properly  applied  bandages  (see  Minor  Surgery).  Firm  and  equable 
compression,  applied  through  the  medium  of  large  cushion-like  dress- 
ings of  gauze  and  cotton,  affords  considerable  comfort  to  the  patient, 
particularly  when  combined  with  proper  position  and  complete  muscu- 
lar relaxation  of  the  injured  parts. 

Revision  of  Dressings  and  Redressing  of  Wounds. — If  with  the 
occurrence  of  swelling  the  compression  is  increased  to  the  extent  of 
giving  rise  to  pain  in  injured  parts  previously  free  from  pain,  or  if  from 
the  restlessness  of  the  patient  or  other  circumstance  the  dressings  be- 
come accidentally  disturbed,  revision  of  the  dressings  is  demanded. 
That  is  to  say,  the  bandages  and  dressing  materials  are  to  be  rearranged, 
and  perhaps  the  position  of  the  injured  parts  altered.  By  the  term 
redressing  is  meant  the  complete  removal  of  one  set  of  dressings  and 
the  application  of  another.  The  indications  for  the  latter  may  be 
simply  stated.  If  anything  goes  wrong  in  the  neighborhood  of  the 
wound,  as  evidenced  by  heat,  pain,  or  soiling  of  the  dressings  ;  or  if 
the  general  well-being  of  the  patient  is  disturbed  by  elevation  of  the 
body-temperature,  headache,  foul  tongue,  malaise,  and  restlessness,  the 
wound  should  be  suspected  of  being  the  cause.  Under  these  circum- 
stances the  injured  parts  should  be  examined  and  redressed,  such 
modifications  of  the  dressings  being  instituted  at  this  time  as  will  meet 
the  particular  indications  found  to  be  present.  Soiling  of  the  dressings 
by  a  simple  serosanguinolent  discharge  that  has  quickly  dried  in  the 
meshes  of  the  gauze  does  not  of  itself  necessarily  indicate  exposure  of 
the  wound.  If  undue  tension  is  present  from  failure  of  drainage,  the 
drains  should  be  cleaned ;  if  the  sutures  are  found  to  be  cutting  into 


104  INTERNATIONAL     TEXT-BOOK  OF  SURGERY. 

the  soft  parts,  these  are  to  be  removed  in  addition.  If  the  line  of 
approximation  shows  that  infection  lias  taken  place,  this  should  be  met 
by  appropriate  means.  If  mild,  as  shown  by  slight  reddening,  wet 
antiseptic  dressings  may  suffice.  If  a  decided  and  extensive  blush  is 
present  the  sutures  must  be  removed  to  give  access  to  the  wound- 
cavity,  which  must  be  thoroughly  cleansed  and  loosely  packed  with 
iodoform  gauze  moistened  with  a  95  per  cent,  alcohol  or  a  2\  per  cent, 
carbolic-acid  solution.  The  former  has  been  found  to  be  exceedingly 
useful  in  rapidly  developed  phlegmonous  inflammation. 

If  no  indication  exists  for  the  revision  of  a  dressing  or  a  re- 
dressing of  the  wound,  it  is  a  surgical  error  to  disturb  the  dress- 
ings, save  for  the  purpose  of  removal  of  drains,  until  the  time  arrives 
for  the  removal  of  the  sutures — say  a  week  or  ten  days.  The  technic 
of  redressings  should  be  conducted  with  the  same  care  as  the  original 
dressing. 

Subcutaneous  Injuries. — Injuries  of  this  character  involving  an 
external  wound  have  already  been  dwelt  upon.  In  this  connection  it 
is  intended  to  deal  only  with  the  parts  which  lie  subjacent  to  the  skin, 
and  which  present  an  unbroken  surface — that  is  to  say,  contusions.  For 
the  detailed  treatment  of  injuries  to  separate  structures  the  reader  is 
referred  to  the  several  chapters  devoted  to  that  subject. 

The  treatment  of  contusions  will  depend  entirely  upon  the  amount 
of  damage  inflicted.  More  or  less  pain  is  usually  suffered  in  conse- 
quence of  the  involvement  of  sensory  nerve-fibers-  in  the  traumatism, 
as  well  as  from  tension  due  to  the  presence  of  hemorrhagic  and  other 
effusions.  For  the  relief  of  the  pain  due  to  the  first-named  cause  the 
application  of  a  lotion  containing  opium  is  useful.  If  this  is  combined 
with  a  2\  per  cent,  solution  of  carbolic  acid  in  the  proportion  of  an 
ounce  of  tincture  of  opium  to  a  pint  of  the  acid,  the  tendency  to  sup- 
purative inflammation  arising  from  infection  of  the  devitalized  struct- 
ures through  such  channels  as  the  hair-follicles  will  be  combated,  and 
the  pain  relieved  as  well.  Care  must  be  exercised  in  the  use  of  both 
of  these  agents  in  very  young  children  and  old  persons,  for  the  reason 
that  absorption  takes  place  readily  in  the  delicate  integumentary  struct- 
ures of  the  former  and  the  atrophied  skin  of  the  latter,  and  toxic 
symptoms  may  be  produced.  The  old-time  remedy  known  as  the 
lead-and-opium  lotion,  consisting  of  a  dram  of  lead  acetate,  an  ounce 
of  tincture  of  opium,  and  a  pint  of  water,  applied  warm,  is  a  grateful 
application  in  painful  contusions.  Rest  and  position,  together  with 
agreeable  compression,  are  of  service  in  relieving  pain  ;  at  the  same 
time  they  reduce  swelling  and  tend  to  arrest  further  hemorrhage.  Hot 
or  cold  water,  the  latter  of  ordinary  room-temperature,  or  an  evapora- 
ting lotion  of  ammonium  chlorid  in  alcohol  and  water,  applied  either 
warm  or  cold,  as  seems  most  acceptable  to  the  patient,  are  to  be  men- 
tioned. If  necessary,  an  incision  may  be  made,  clots  turned  out,  and 
bleeding  vessels  sought  and  secured.  The  readiness  of  tissues  that 
are  the  seats  of  a  contusion  to  take  on  suppurative  inflammation  under 
the  influence  of  mildly  infectious  agents  should  be  remembered,  and 
strict  precautionary  measures  should  be  taken  accordingly. 

If  seen  early,  massage  will  be  found  to  shorten  materially  the  period 
of  disability  due  to  the  contusion.     It  is  always  indicated  in  those  cases 


WOUNDS.  105 

in  which  there  is  no  injury  to  important  underlying  structures  and  no 
infection.  Massage  may  be  employed  later  in  the  treatment  and  after 
the  subsidence  of  sensitiveness,  for  the  purpose  of  hastening  the  ab- 
sorption of  effusions.  This  measure  of  treatment  is  particularly  valuable 
in  subcutaneous  injuries  occurring  in  the  neighborhood  of  joints.  For 
the  rapid  removal  of  the  discoloration  following  contusion,  gentle  fric- 
tion with  alcohol  and  daily  pencilling  the  part  lightly  with  tincture  of 
iodin  will  be  found  useful.  In  contusion  occurring  in  very  lax  tissues, 
as  in  the  neighborhood  of  the  eye,  aspiration  of  the  effused  fluid  may 
be  tried,  if  the  condition  is  seen  early.  If  tension  upon  the  cavity-walls 
is  such  as  to  prevent  absorption,  or  if  blood-coagula  fail  to  disappear 
through  the  natural  processes  of  elimination  occurring  in  connection 
with  new- tissue  formation  (the  so-called  clot  organization),  they  must 
be  evacuated  through  an  incision.  The  prolonged  presence  of  such 
clots  in  the  subcutaneous  connective  tissue  is  apt  to  lead  finally  to 
suppuration. 

Poisoned  Wounds — Post-mortem  or  dissection  wounds  may  be 
taken  as  a  type  of  infected  wounds  which  exhibit  a  tendency  to  special 
virulency,  and  are  generally  considered  as  a  class  by  themselves.  They 
are  characterized  by  pronounced  local  and  general  infection,  and  are 
of  frequent  occurrence  among  those  employed  in  making  autopsies 
and  in  dissecting-room  students.  Wounds  received  by  the  surgeon  in 
conducting  operations  upon  infected  individuals  may  give  rise  to  the 
same  train  of  symptoms.  By  far  the  greater  number,  however,  are  re- 
ceived in  the  dead-house,  in  which  case  they  are  usually  the  result  of 
the  examination  of  bodies  recently  dead  from  such  infectious  diseases  as 
septic  peritonitis,  erysipelas,  pyemia,  and  septicemia,  and  give  rise  to 
severe  and  even  dangerous  symptoms.  Comparatively  few  of  these 
accidents  occur  among  dissecting-room  students,  for  the  reason  that  the 
infective  micro-organisms  soon  lose  their  virulency  and  are  replaced  by 
the  bacteria  of  putrefaction.  When  they  do  occur  under  these  circum- 
stances, the  infection  is  usually  followed  by  only  a  very  moderate  local 
reaction  and  comparatively  mild  symptoms  of  a  general  character. 

It  is  unlikely  that  the  special  virulency  of  these  cases  depends  upon 
any  one  specific  organism,  but  on  the  contrary,  in  the  majority  of  in- 
stances the  infection  is  a  mixed  one,  streptococci  predominating.  This 
is  particularly  apt  to  be  the  case  in  infectious  processes  occurring  in 
surgeons,  hospital  internes,  and  nurses  from  contact  with  certain  cases 
of  cellulitis.  It  is  a  well-known  fact  that  some  individuals  are  more 
susceptible  to  infection  than  others ;  and  further,  that  those  who  are 
more  or  less  constantly  in  contact  with  infectious  material  acquire  a 
certain  degree  of  immunity. 

While  the  commonest  mode  of  entrance  of  the  poison  is  through  a 
wound,  this  latter  need  not  necessarily  be  severe  or  have  been  received 
at  the  time  of  the  inoculation.  In  fact,  it  is  believed  that  the  infection 
is  oftener  conveyed  through  pre-existent  abrasions,  slight  wounds,  and 
the  trifling  fissures  in  the  skin  occurring  at  the  ungual  margins,  and 
known  as  "  hang-nails,"  than  through  recent  or  severe  wounds.  The 
reason  for  this  probably  resides  in  the  fact  that  more  or  less  bleeding 
and  inability  to  continue  the  work  accompany  the  latter,  the  poison 
being  thus  removed,  and  prompt  measures   of  disinfection  resorted  to. 


106  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

Absorption  of  the  poison  may  occur  also  through  the  sweat-glands  or 
sebaceous  glands.  Those  in  ill  health  are  more  susceptible  than  robust 
individuals. 

Symptoms. — The  most  striking  characteristics  of  the  hyperacute 
cases  of  poisoned  wounds  are  rapidity  of  development  of  the  local  in- 
fectious process,  accompanied  by  serosuppurative  inflammation  and 
sloughing,  and  the  early  supervention  of  symptoms  of  systemic  poi- 
soning. As  a  rule,  the  severity  of  the  latter  depends  upon  the  degree 
and  intensity  of  the  former.  Occasionally,  however,  general  symptoms 
of  acute  septic  intoxication,  out  of  all  proportion  to  the  local  conditions, 
are  observed.  In  these  cases  the  local  signs  are  often  slight.  The 
point  of  entrance  of  the  infection  exhibits  a  slight  edema ;  a  small 
vesicle  filled  with  serosanguinolent  fluid  is  sometimes  observed.  As  a 
rule,  there  is,  however,  intense  pain  at  the  seat  of  inoculation.  Early 
collapse  supervenes,  with  rapid  and  feeble  pulse,  elevation  of  tempera- 
ture, jactitation,  subsultus  tendinum,  and  delirium  followed  by  uncon- 
sciousness. Death  may  occur  in  forty-eight  hours.  In  other  cases 
these  symptoms  follow  the  occurrence  of  acute  cellulitis.  This  condi- 
tion is  ushered  in  by  malaise,  local  pain,  rigors,  and  vomiting.  Swelling 
of  the  parts  in  the  neighborhood  of  the  wound,  with  rapid  sloughing 
of  the  tissues  and  early  formation  of  pus,  occurs.  The  cellulitis  rapidly 
extends  up  the  arm  to  the  shoulder,  and  may  even  invade  the  soft 
parts  upon  the  chest-wall. 

In  more  commonly  observed  cases,  particularly  in  dissecting-room 
wounds  and  in  those  occurring  in  surgeons  and  their  assistants,  the  in- 
vasion is  of  a  milder  type.  The  wound  becomes  painful,  red,  and  but 
slightly  swollen.  A  papule  or  pustule  develops,  and  there  is  but  little 
to  attract  attention  to  more  remote  parts  until  a  series  of  red  lines  is 
discovered  running  up  the  arm,  marking  the  spread  of  infection  by  the 
lymphatic  vessels.  These  may  sometimes  be  felt  as  knotted  cords,  and 
may  continue  to  be  so  felt  for  a  long  time  following  the  attack.  The 
lymphatic  glands  soon  become  involved.  If  limited  to  the  superficial 
group,  the  glands  in  front  of  the  elbow,  or  those  above  the  internal 
condyle,  are  affected.  If  involvement  of  the  deep  set  occurs,  the  large 
glands  in  the  axilla  become  swollen,  painful,  and  tender.  In  either  case 
suppuration  is  apt  to  follow,  although  it  does  not  necessarily  occur,  the 
process  rapidly  subsiding.  In  case  glandular  abscess  follow,  the  patient 
will  complain  of  chilly  sensations,  and  a  rise  in  temperature  will  be 
observed.  With  the  opening  and  evacuation  of  the  abscess-cavities  the 
symptoms  rapidly  disappear.  In  this  class  of  cases  the  lymphatic 
glands  interpose  a  barrier  against  general  infection,  acting  in  conjunc- 
tion with  a  high  degree  of  vital  resistance  on  the  part  of  the  indi- 
vidual. 

In  another  class  of  cases,  depending  upon  the  virulence  of  the  poi- 
son and  the  degree  of  resistance  of  the  injured  person,  the  cellulitis 
may  assume  the  character  of  an  ordinary  phlegmonous  inflammation, 
with  brawniness,  excessive  pain,  a  high  degree  of  tension,  and  diffused 
redness  of  the  surface ;  or  these  symptoms  may  be  replaced  by  simple 
swelling  and  edema. 

The  situation  and  depth  of  the  wound  will  govern  to  some  extent 
the  rapidity  of  development  of,  as  well  as  the  routes  travelled  by,  the 


WOUNDS.  107 

infection  and  the  symptoms.  Wounds  penetrating  the  palmar  fascia 
follow  the  sheaths  of  the  flexor  tendons  and  lead  to  suppurative  col- 
lections above  the  annular  ligament  of  the  wrist.  Wounds  upon  the 
dorsal  aspect  of  the  hand  or  forearm  are  of  far  less  serious  import. 

Treatment. — Prophylaxis  is  of  the  first  importance.  The  hands  of 
the  postmortemist  should  be  previously  smeared  with  vaselin  or  lard 
as  a  preventive  of  infection  through  unobserved  abrasions  or  the  gland- 
ular structures  of  the  skin.  Deeply  staining  the  hands  with  a  fluid 
'made  by  adding  to  a  1  :  1000  corrosive-sublimate  solution  sufficient 
potassium-permanganate  crystals  to  make  a  saturated  solution  of  the 
latter,  as  originally  devised  by  myself  for  the  purpose  of  disinfecting 
the  hands  of  the  operating  surgeon,  may  be  employed  with  advantage. 
The  advantage  of  this  method  of  preparing  the  hands  lies  in  the  fact 
that  the  affinity  of  the  coloring  matter  of  the  permanganate  for  the 
deeper  structures  of  the  skin  causes  more  decided  penetration  of  the 
latter,  both  on  the  part  of  this  agent  and  of  the  mercurial  compound. 
The  original  object  in  employing  this  combination  in  the  manner  de- 
scribed was  the  insurance  of  a  more  thorough  disinfection  of  the  deeper 
portions  of  the  skin,  the  stain  being  permitted  to  remain  during  the 
entire  operation.  It  is  afterward  removed  by  immersing  the  hands  in 
a  warm  saturated  solution  of  oxalic  acid,  after  which  the  latter  is  neu- 
tralized by  lime  water  or  weak  ammonia  water.  It  was  soon  found 
that,  in  addition  to  this  advantage,  the  surgeons,  internes,  and  nurses 
employing  this  method  acquired  an  immunity  against  the  occurrence 
of  so-called  "  pus  fingers  "  never  before  enjoyed. 

No  person  should  engage  in  an  autopsy  who  has  a  palpable  wound 
upon  the  hand.  Hang-nails  especially  constitute  a  source  of  danger. 
In  case  a  wound,  even  though  it  be  of  a  slight  nature,  is  received 
during  an  autopsy  or  in  the  course  of  operation  upon  an  infected  sub- 
ject, prompt  measures  are  to  be  taken  to  prevent  serious  conse- 
quences. The  wounded  part  is  to  be  isolated  from  the  general  circu- 
lation by  the  application  of  a  bandage  above.  This  should  be  suf- 
ficiently tight  to  prevent  the  return  circulation  from  taking  place,  yet 
not  so  tight  as  to  interfere  with  the  blood-supply.  Bleeding  is  thus 
encouraged.  The  wound  is  then  washed  in  a  5  per  cent,  carbolic 
solution,  or  a  1  :  1000  sublimate  solution,  after  which  the  wound  is 
sucked  and  cauterized  with  the  solid  nitrate-of-silver  stick,  or  swabbed 
with  a  30  gr. :  3j  solution  of  zinc  chlorid.  The  constricting  bandage 
should  now  be  removed  and  a  dressing  of  gauze  wet  with  a  2\  per 
cent,  solution  of  carbolic  acid,  to  which  has  been  added  tincture  of 
opium  in  the  proportion  of  an  ounce  to  the  pint,  applied.  The  dress- 
ings should  be  moistened  occasionally  with  the  same  solution. 

With  the  actual  occurrence  of  infection,  as  shown  by  the  formation 
of  a  bleb  or  pustule  at  the  site  of  the  injury,  the  surroundings  should 
be  thoroughly  washed  with  soap  and  warm  water,  disinfected  with  a 
1  :  1000  solution  of  sublimate,  and  the  pustule  opened  or  the  wound 
freely  enlarged,  and  curetted.  If  only  a  bleb  is  present  the  cuticle  of 
this  is  to  be  trimmed  away  and  the  infected  area  incised  freely.  Moist 
warm  dressings  of  the  carbolic-and-opium  lotion  should  then  be  ap- 
plied. If  a  cellulitis  spread  up  the  arm  the  latter  should  be  suspended 
in  a  hot  bath  of  1  :  5000  sublimate  solution  for  an  hour  at  a  time,  this 


I08  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

alternating  with  the  warm  moist  carbolic-and-opium  lotion.  If  the 
area  of  infection  is  large,  or  if  for  any  other  reason  it  is  deemed  inad- 
visable to  employ  a  lotion  freely,  Biirow's  solution  may  be  used.  This 
consists  of  5  parts  of  lead  acetate,  25  parts  of  alum,  and  500  parts  of 
water.  A  hot  bath  of  the  latter  may  also  take  the  place  of  the  sub- 
limate bath.  In  placing  the  arm  in  the  bath  a  hammock-like  arrange- 
ment should  be  improvised  to  prevent  constriction  due  to  resting  the 
arm  upon  the  edge  of  the  vessel. 

The  local  conditions  should  be  carefully  watched  and  incisions 
made  from  time  to  time,  as  needed,  to  lessen  tension,  relieve  pain,  and 
give  exit  to  purulent  material.  The  incisions  should  be  just  deep  and 
extensive  enough  to  effect  this  object ;  if  carried  beyond  this  point, 
extension  of  infection  to  deeper  and  more  remote  parts  will  be  apt  to 
occur.  Infectious  processes  conveyed  along  the  course  of  sloughing 
tendinous  sheaths  to  distant  and  deeply  placed  areas  require  the  ex- 
cision of  the  sheaths  as  well  as  of  the  tendons  themselves.  While  this 
course  is  always  to  be  deprecated,  leading  as  it  does  to  irreparable  loss 
of  function,  it  is  to  be  preferred  to  the  risks  involved  in  permitting  viru- 
lent infection  to  reach  inaccessible  parts.  Amputation  may  even  be 
required. 

The  general  treatment  consists  of  forced  nourishment,  the  free  use 
of  alcoholic  stimulants,  and  the  administration  of  quinin  in  doses  of 
5  or  more  grains,  combined  with  the  tincture  of  the  chlorid  of  iron. 
The  more  threatening  the  septic  intoxication  the  more  urgently  these 
measures  are  demanded.  Experience  tends  to  encourage  the  use  of 
antistreptococcic  serum  in  these  cases  in  the  same  manner  as  in  septic 
peritonitis,  viz.,  20  c.c.  of  the  Marmorek  serum  injected  in  the  region 
of  the  buttocks,  and  repeated  in  10  c.c.  doses  every  six  hours  until 
amelioration  of  the  symptoms  is  noted  or  the  case  is  decidedly  a  hope- 
less one.  Diarrhea,  which  is  apt  to  occur,  should  be  held  in  check. 
If  pain  is  excessive  and  not  relieved  by  the  local  applications,  morphin 
is  to  be  employed  hypodermically.  During  convalescence  the  patient 
should  be  carefully  nourished,  and  change  of  air  and  surroundings 
recommended. 

Anatomical  Tubercle. — This  is  a  name  applied  to  a  chronic  thick- 
ening of  isolated  portions  of  the  back  of  the  hand,  over  the  knuckles 
and  metacarpal  bones,  occurring  among  those  who  habitually  handle 
the  dead  bodies  of  either  men  or  animals.  It  seems  to  be  particularly 
prone  to  occur  in  these  regions  on  account  of  the  thin  skin  over  the 
latter ;  occasionally,  although  very  rarely,  it  has  been  found  upon  the 
forearm,  and  has  been  observed  upon  the  borders  of  the  nails,  as  well 
as  upon  cicatrices  marking  the  site  of  old  post-mortem  wounds.  In 
former  times,  on  account  of  its  resemblance  to  lupus,  it  was  known  as 
lupus  anatomicus,  and  recent  investigations  seem  to  show  that  the  con- 
dition is  actually  an  inoculation  of  the  tubercle  bacillus.  There  is  no 
evidence,  however,  that  generalization  of  the  infection  ever  occurs  from 
this  source.  It  is  probable,  therefore,  that  all  cases  are  not  of  a  specific 
nature,  but  that  the  majority  of  these  are  the  result  of  constant  contact 
with  putrid  animal  matter. 

The  tubercles  themselves  resemble  common  warts,  and  consist  of 
papular  growths,  made   up  of  enlargements  of  the  cutaneous  papillae 


WOUNDS.  IO9 

occurring  in  circumscribed  limits,  and  forming  small  tender  areas  with 
uneven  surfaces.  These,  upon  being  irritated,  furnish  a  thin  serum, 
which  upon  drying  forms  a  scab.  They  are  covered  with  a  layer  of 
thickened  and  opaque  epidermis  of  a  bluish-red  color.  On  the  borders 
of  the  nails  the  affection  occurs  as  isolated  nodules.  In  some  instances 
the  disease  takes  the  form  of  an  eczema,  such  as  is  found  upon  the 
knuckles  of  plasterers.  The  course  of  the  affection  is  essentially  a 
chronic  one,  with  a  tendency  to  recovery  when  the  exciting  cause  is 
removed. 

The  treatment  consists  in  the  removal  of  the  cause,  either  by  pro- 
tecting the  hands  with  rubber  gloves  or  discontinuing  the  work  alto- 
gether. If  persistent  in  spite  of  these  measures,  the  application  of  the 
acid  nitrate  of  mercury  or  fuming  nitric  acid  will  accomplish  their 
removal.  In  case  of  extensive  involvement  of  the  back  of  the  hand 
the  parts  should  be  thoroughly  curetted  and  dressed  with  Burow's 
solution,  or  the  borosalicylic  solution  of  Prof.  Thiersch. 

Modifying  Influences  Affecting  Repair — Hygienic  conditions  exert 
a  modifying  influence  upon  the  healing  of  wounds.  They  include  the 
relations  which  climatic  and  atmospheric  conditions,  temperature,  sun 
light,  and  food  bear  to  the  general  well-being  of  the  individual.  In 
those  countries  in  which,  from  the  continued  high  temperature,  an  out- 
of-door  life  on  the  part  of  the  inhabitants  is  necessary,  healing  takes 
place  more  readily  than  among  those  living  where  cold  weather  and 
dampness  prevail.  Again,  moderately  warm  weather  indirectly  favors 
repair  by  the  necessity  that  exists  for  keeping  the  doors  and  windows 
open,  thus  insuring  a  constant  supply  of  fresh  air,  as  well  as  sunlight. 
With  changing  barometric  conditions  the  mortality  from  injuries  and 
operations  is  said  to  vary  greatly. 

According  to  Hewson's  observations,  based  upon  a  study  of  the  meteorological  records 
and  the  records  of  the  surgical  service  of  the  Pennsylvania  Hospital  extending  over  a  period 
of  thirty  years,  the  lowest  mortality  occurred  with  a  rising  barometer.  This  was  nearly 
doubled  with  a  stationary  barometer,  and  with  a  falling  barometer  it  was  more  than  doubled. 
The  low  barometrical  pressure  bore  a  direct  relation  to  general  infection  from  local  septic 
conditions  in  wounds. 

The  necessity  of  a  liberal  supply  of  sunlight  and  fresh  air  cannot  be 
too  strongly  emphasized,  nor  can  the  influence  of  these  upon  nutrition 
be  overestimated,  particularly  under  conditions  in  which  there  is  de- 
pression of  the  vital  powers.  The  processes  of  repair  which  take  place 
in  the  tissues  have  been  likened  to  those  occurring  in  the  growing 
child  (Pilcher).  The  effects  of  sunlight  and  fresh  air  have  always  been 
matters  of  common  observation,  and  mark  an  instinctive  craving  for 
these  aids  to  healthy  development  exhibited  by  all  living  creatures. 
Their  presence  reinforces  the  general  powers  of  resistance  on  the  part 
of  the  individual ;  while  their  absence,  particularly  the  absence  of  a  lib- 
eral supply  of  fresh  air,  not  only  entails  a  lessening  of  this  quality 
already  possessed  by  the  patient,  but  likewise  leads  to  an  increased 
accumulation  of  infectious  matters  from  the  bodily  exhalations  of  the 
patient,  of  those  in  attendance  upon  him,  and  of  others  confined  in 
the  same  ward.  The  necessity  for  measures  to  provide  fresh  air  to 
those  in  health  emphasizes  the  importance  of  redoubling  these  meas- 
ures in  the  case  of  the  injured. 


IIO  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

The  necessity  for  a  good  supply  of  nourishing  and  easily  digested 
food  should  be  insisted  upon,- for  in  the  absence  of  it  wounds  do  not 
heal  quickly.  Under  circumstances  of  limited  supply  of  food-material, 
particularly  if  the  food  is  of  a  coarse  and  unwholesome  character,  and 
perhaps  badly  cooked  as  well,  the  reparative  process  will  be  arrested, 
and  retrogressive  and  degenerative  changes  initiated  and  perpetuated. 
The  digestive  powers  of  the  injured  person  should  be  carefully  studied, 
and  the  important  influences  of  diet  upon  his  early  restoration  to  health 
and  usefulness  should  be  thoroughly  appreciated  by  the  surgeon. 

The  Mental  State. — The  importance  of  maintaining  cheerful  sur- 
roundings has  not  met  with  the  attention  which  it  deserves.  It  is  a 
well-known  fact  that  the  wounds  of  those  defeated  in  battle  heal  much 
less  readily  than  those  of  a  victorious  army.  The  influence  of  the  mind 
upon  the  body  is  such  that  the  reparative  processes  are  more  or  less 
influenced  by  mental  conditions.  Observations  in  the  wards  of  large 
metropolitan  hospitals  constantly  impress  one  with  these  facts.  Those 
patients  who  have  recently  landed  from  emigrant  ships,  with  no  homes 
established  in  this  country,  as  well  as  those  brought  from  lodging- 
houses  and  having  neither  home  nor  friends,  heal  slowly,  in  spite  of 
improvement  in  their  bodily  condition  arising  from  proper  hygienic  sur- 
roundings and  better  food.  This  can  be  reasonably  attributed  to  anxiety 
and  fear  as  to  their  future.  On  the  other  hand,  healing  is  undoubtedly 
promoted  by  the  opposite  conditions  of  hope  and  confidence,  as  ex- 
hibited by  those  who  receive  the  visits  of  cheerful  friends  and  look 
forward  to  return  to  their  poor  but  happy  homes. 

Age. — The  healing  of  wounds  is  accomplished  with  much  greater 
facility  in  the  young  than  in  those  in  middle  life,  or  the  aged.  This  is 
due,  first,  to  the  fact  that  the  reparative  power  is  greater ;  and  second, 
to  the  greater  freedom  from  pre-existing  organic  disease.  As  a  general 
rule,  it  may  be  stated  that  the  healing  power  progressively  diminishes 
after  the  thirtieth  year  of  life.  Large  wounds  heal  slowly  in  the  aged, 
who  are  apt  to  succumb  to  slight  causes  while  the  reparative  process  is 
in  progress.  On  the  other  hand,  wounds  heal  promptly  in  the  young, 
and  parts  which  in  those  of  more  advanced  age  require  removal  be- 
cause of  an  excessive  crushing  effect,  in  young  patients  regain  their 
vitality,  and  finally  their  function,  in  a  most  astonishing  manner,  and 
that,  apparently,  without  noticeable  drain  upon  the  patient's  vital  re- 
sources. 

Constitutional  and  Diseased  Conditions. — Under  this  head  are  to  be 
grouped  nutritive  disturbances  due  to  actual  disease,  and  to  general 
states  of  the  blood  which  do  not  necessarily  constitute  a  recognizable 
disease.  Marked  anemia,  on  the  one  hand,  and  plethora,  upon  the 
other;  the  direct  effects  of  starvation  upon  the  tissues,  and  the  results 
of  gluttony;  conditions  arising  from  the  excessive  use  of  alcoholic 
stimulants  ;  the  exhaustion  from  overwork  and  intellectual  strain — all 
of  these,  as  well  as  the  effect  upon  bodily  nutrition  of  vicious  habits 
and  such  other  influences  as  tend  to  lower  the  general  vital  resistance, 
should  be  taken  at  their  full  value  in  estimating  the  prognosis  in  indi- 
vidual cases  of  extensive  wounds. 

The  most  serious  of  the  complications  of  the  general  system  to 
which  wounds  are  subject  are  those  arising  from  the  pre-existence  of 


BUKNS  AND   SCALDS.  I  I  l 

pyemia  and  septicemia.  The  presence  of  a  local  and  virulent  infection, 
such  as  erysipelas,  adds  a  special  source  of  danger.  Local  suppurative 
conditions  in  parts  subsequently  subjected  to  accidental  wounds  lead  to 
infection  of  the  latter  as  well  as  to  a  spread  of  the  original  suppuration. 
Differences  between  accidental  and  operation  wounds  reside  in  the  fact 
that  the  latter  are  incised  wounds  with  clean-cut  edges,  and  are  planned 
with  the  view  of  evacuating  collections  of  pus  and  relieving  tension, 
while  the  former  are  usually  of  a  contused  or  lacerated  character.  The 
latter  inflict  great  damage  upon  surrounding  structures,  thus  inviting 
spread  of  pre-existing  suppurative  conditions. 

Certain  diseases  which  give  rise  to  general  defects  of  nutrition  in- 
terfere greatly  with  the  healing  of  wounds,  and  measures  to  combat 
these  should  be  instituted  early.  Among  these  may  be  mentioned 
tuberculosis,  syphilis,  diabetes  mellitus,  and  malaria.  In  the  presence  of 
these  complications  the  surgical  clinician  will  find  ample  opportunity 
of  drawing  upon  his  therapeutic  resources  in  promoting  prompt  heal- 
ing. Of  still  greater  importance,  because  of  greater  difficulties  of 
management,  is  the  presence  of  organic  changes  in  important  organs, 
such  as  the  lungs,  heart,  liver,  and  kidneys.  The  three  last-named  or- 
gans are  frequently  the  subjects  of  interdependent  disease,  and  when  a 
well-defined  pathologic  change  is  discovered  in  the  one,  the  two  others 
should  be  made  the  subject  of  careful  investigation.  The  seriousness 
of  these  organic  diseases,  in  addition  to  the  relation  which  their  stage 
of  advancement  at  the  time  of  the  infliction  of  the  wound  bears  to  the 
healing  of  the  latter,  arises  from  the  fact  that  the  pre-existing  affection 
is  temporarily  at  least,  and  frequently  permanently,  aggravated  by  the 
injury.  This  may  be  the  direct  cause  of  death,  and  failure  to  recognize 
and  provide  against  such  a  contingency  in  cases  of  personal  assaults 
where  the  wounds  received  are  of  themselves  insufficient  to  cause  death, 
may  lead  to  serious  medico-legal  complications. 

BURNS  AND  SCALDS. 

Certain  chemical  and  physical  effects  occur  as  the  result  of  exposure 
of  portions  of  the  body  to  excessive  heat.  To  this  class  also  belong 
injuries  caused  by  caustic  substances,  such  as  concentrated  acids  and 
caustic  alkalies.  Disturbances  consisting  of  changes  in  the  skin  and 
circulator}'  channels,  and  varying  according  to  the  temperature  and 
length  of  time  of  exposure  of  the  part,  are  observed.  The  inflamma- 
tory conditions  present  are  not  essential,  but  accessory. 

Degrees  of  Burns. — A  momentary  exposure  to  a  temperature 
somewhat  below  the  boiling  point  of  water  produces  an  overfilling  of 
the  smaller  arteries,  due  to  a  simple  paralysis  of  the  constrictor  muscles 
of  these.  The  resulting  increased  quantity  of  blood  in  the  parts  occa- 
sions the  hyperemia  or  redness  observed  under  these  circumstances. 
This  is  known  as  a  burn  of  the  first  degree. 

Burns  of  the  second  degree  include  those  in  which  blistering  takes 
place.  Here  there  is  an  exudation  of  serous  fluid  into  the  tissues,  par- 
ticularly the  rete  Malpighii.  A  portion  of  the  epidermal  layer  is  lifted 
up,  constituting  the  covering  of  the  blister. 

Bums  op  the  third  degree  are  the  result  of  albuminous  coagulation 


112  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

affecting  the  contents  of  the  vessels  and  the  serous  fluid  and  albumin- 
ous substance  of  the  tissues.  Greater  or  less  areas  are  deprived  of 
nourishment,  and  necrosis  of  tissue  follows.  An  exaggeration  of  this 
degree  constitutes  the  fourth  and  fifth  degrees  of  some  authors,  these 
terms  being  applied  to  either  charring  of  the  skin  or  of  the  skin  and 
the  muscular  structures  as  well. 

Inflammatory  Conditions  Following  Burns. — The  condition 
of  hyperemia  which  occurs  in  burns  of  the  first  degree  somewhat  re- 
sembles an  inflammation.  This  hyperemia,  however,  disappears  spon- 
taneously after  a  comparatively  short  time.  In  cases,  however,  of 
burns  of  the  second  or  third  degree  the  situation  is  vastly  changed, 
opportunity  being  afforded  for  the  entrance  and  propagation  of  bac- 
teria. In  burns  of  the  second  degree,  if  the  vesicles  are  not  disturbed, 
healing  may  take  place  beneath  the  raised  layer  constituting  the  sur- 
face of  the  blister.  When  these  are  ruptured,  more  or  less  infection 
and  inflammatory  complications  may  follow,  as  a  consequence.  In 
burns  of  the  third  degree  the  infection  takes  place  from  the  margins  of 
the  burn,  which,  as  a  rule,  are  not  carbonized,  and  not  from  the  area  of 
charred  tissue,  since  here  the  usual  and  readiest  channels  of  infection 
are  closed.  From  the  margins  of  the  eschar  a  slowly  progressing  sup- 
purative inflammation  goes  on,  the  neighboring  structures  partaking  of 
this  to  a  greater  or  less  extent.  By  means  of  this  suppuration  of. 
demarcation,  as  it  is  called,  the  necrotic  tissue  is  slowly  lifted  up  and 
separated  from  the  living  structures  beneath.  This  suppuration  of  de- 
marcation may  give  place  to  a  phlegmonous  inflammatory  condition, 
in  which  case  the  line  of  demarcation  is  not  formed,  but  a  necrosis  of 
inflammatory  origin  may  become  associated  with  that  arising  from  the 
burn.  In  this  manner  large  areas  of  tissue  sometimes  become  involved 
in  the  gangrenous  process.  The  suppuration  of  demarcation  is  not 
always  marked.  The  charred  portion  is  not  a  favorable  soil  for  the 
development  of  bacteria,  owing  to  the  fact  of  the  coagulation  of  its 
albuminous  elements.  If  efforts  to  prevent  the  entrance  of  bacteria  at 
the  margins  by  the  early  employment  of  antiseptic  measures  prove 
successful,  the  entire  separation  of  the  necrotic  portion  may  occur  with 
scarcely  a  trace  of  suppuration.  The  formation  of  new  vessels  goes 
rapidly  forward,  and  the  young  vascular  connective  tissue  crowds  to- 
ward the  necrotic  tissue.  In  this  way  an  aseptic  granulation-process 
replaces  the  suppuration  of  demarcation,  and  a  process  of  elimination 
of  the  dead  part  follows.  This  eliminative  process  occasionally  takes 
a  very  long  time,  particularly  in  cases  in  which  bone  is  involved.  It 
may  demand  artificial  aid.  Following  the  separation  and  removal  of 
the  necrotic  tissue  a  correspondingly  large  granulating  wound  is  pres- 
ent, which  gradually  becomes  covered  in  as  a  skin-defect.  The  cica- 
trices following  burns  are  apt  to  give  rise  to  serious  deformities  as  well 
as  to  various  disturbances  of  function,  such,  for  instance,  as  permanent 
flexure  of  the  joints  in  the  extremities,  ectropion  of  the  eyelids,  etc. 

Constitutional  Symptoms. — In  cases  of  extensive  burns  the 
patient  usually  complains  of  great  pain  in  the  original  part,  although 
in  carbonization  of  an  entire  extremity  comparatively  slight  pain  may 
be  felt,  the  burned  area  and  its  neighborhood  being  almost  completely 
anesthetic  in  the  commencement.       The  patient  is  usually  in  a  state  of 


BUBNS  AXD    SCALDS.  I  I  3 

great  mental  excitement,  is  very  restless  and  tosses  about  in  bed, 
screaming  and  crying  with  combined  fright  and  pain  ;  in  other  cases 
he  lies  in  an  apathetic  state.  In  rapidly  fatal  cases  delirium  and  con- 
vulsive movements  come  on  early,  with  extremely  rapid  and  thready 
pulse  and  subnormal  temperature.  Vomiting  and  intense  thirst  are 
pronounced  symptoms  in  these  cases.  The  urine  is  scanty ;  complete 
suppression  may  occur.  The  renal  secretion  is  not  infrequently  red- 
dened from  the  presence  of  hemoglobin.  The  cause  of  the  latter  is 
the  destruction  of  the  red  blood-corpuscles  which  were  in  the  vessels 
of  the  affected  part  at  the  time  of  burning. 

The  patient  may  rail}'  from  the  first  shock  and  give  promise  of  re- 
covery for  the  first  few  days,  only  to  develop  the  above  symptoms  in 
the  stage  of  inflammatory  reaction.  He  may  perish  within  a  few  hours 
of  their  appearance,  or  he  may  linger  on  only  to  succumb  finally  to 
some  of  the  complicating  sequelae.     (See  Prognosis.) 

Prognosis. — In  young  children  burns  of  the  first  degree,  even  if 
of  but  limited  extent,  may  prove  fatal.  Still  smaller  areas  of  the  sec- 
ond and  third  degrees  may  also  result  fatally.  The  involvement  of 
large  areas  of  the  surface  of  the  body  in  burns  of  the  second  and  third 
degrees  invoke  direct  danger  to  life.  In  the  adult,  if  more  than  two- 
thirds  of  the  surface  is  involved  in  a  burn  of  the  first  degree,  life  is 
usually  destroyed ;  while  if  one-third  of  the  surface  is  burned  to  the 
second  or  third  degree,  death  will  almost  inevitably  result.  The 
locality  of  the  burn  should  be  taken  into  account  in  stating  the  prog- 
nosis. Burns  about  the  thoracic  and  abdominal  regions  are  to  be  re- 
garded more  seriously  than  those  of  comparatively  larger  area  or 
greater  severity  elsewhere. 

Death  following  burns  may  result  directly  from  shock.  Reflex 
cardiac  paralysis  may  be  due  to  over-stimulation  of  the  superficial  sen- 
sory nerves.  When,  on  the  other  hand,  reaction  is  established,  con- 
gestion of  internal  organs  is  to  be  feared.  This  may  result  from  vaso- 
motor paresis,  or  from  blood-stasis  due  to  excessive  destruction  of  red 
blood-corpuscles  and  their  conversion  into  small  globules.  The  sec- 
ondary dangers  relate  to  prolonged  suppuration,  exhaustion,  erysipelas, 
pyemia,  septicemia,  and  tetanus.  Scalds  of  the  mouth  and  fauces  may 
be  followed  by  edema  of  the  glottis. 

The  Treatment  of  Burns. — The  local  treatment  of  burns  of  the 
first  degree  is  mainly  directed  to  the  alleviation  of  the  pain.  This  may 
be  accomplished  best  by  dusting  over  the  parts  with  powdered  starch 
or  zinc  oxid,  enveloping  afterward  in  cotton  wool,  and  elevating,  if  the 
part  affected  be  a  limb.  If  the  pain  is  excessive  it  may  be  allayed  by 
the  hypodermic  use  of  morphin.  The  application  of  an  ice-bag,  or 
lead-water  compresses  with  ice,  is  useful. 

In  burns  of  the  second  degree  the  extent  and  severity  of  the  re- 
sulting inflammatory  complications  will  be  in  direct  proportion  to  the 
amount  of  infection  which  occurs.  Therefore,  where  there  is  the 
slightest  vesication  the  practitioner  should  bear  in  mind  the  necessity 
for  early  aseptic  and  antiseptic  measures.  Blebs  should  be  evacuated, 
when  tense,  through  punctures,  but  the  elevated  epidermis  should  not  be 
removed.  Cleansing  of  the  burned  area  is  indicated,  followed  by  antiseptic 
irrigation  (1  :  1000  bichlorid  solution,  or  3  per  cent,  carbolic  solution), 


114  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

and  the  application  of  an  antiseptic  powder  dressing,  such  as  iodoform, 
zinc  oxid,  bismuth  subnitrate,  boric  acid,  etc.  The  whole  may  be  cov- 
ered with  sterilized  non-absorbent  cotton  and  bandaged  with  gauze 
rollers.  Nitzche's  linseed-oil  varnish  consists  of  i  part  of  lead  oxid 
dissolved  in  25  parts  of  boiled  linseed  oil,  to  which  is  added,  while  the 
oil  is  hot,  5  or  10  per  cent,  of  salicylic  acid.  This  is  painted  over  the 
burn  after  the  part  has  been  carefully  disinfected,  and  is  covered  by 
cotton  wool  held  firmly  in  place  by  a  bandage.  Whatever  dressing  is 
employed,  the  same  rule  as  regards  redressing  holds  good  here  as 
elsewhere — namely,  unless  special  indications  exist  demanding  it,  the 
less  often  redressing  is  done  the  better.  In  extensive  burns  the  per- 
manent warm  bath  may  sometimes  be  employed  with  advantage. 

In  cases  in  which  extensive  and  deeply  burned  areas  are  present, 
involving,  for  instance,  a  considerable  portion  of  a  limb,  removal  by 
amputation  will  become  necessary.  The  amputation  should  be  per- 
formed as  soon  as  possible  after  the  symptoms  of  shock  have  subsided. 
The  removal  of  sloughs  is  always  indicated,  and  should  be  practised 
wherever  feasible,  both  in  order  to  get  rid  of  the  putrefying  masses  as 
rapidly  as  possible,  as  well  as  to  obtain  access  to  the  parts  beneath 
for  the  purposes  of  a  more  thorough  antisepsis.  The  poisonous  nature 
of  many  antiseptics  should  be  borne  in  mind,  and  caution  should  be 
exercised  in  making  applications  to  extensively  denuded  or  large 
granulating  surfaces.  Borosalicylic  solution  (Thiersch's)  for  moist 
dressings,  and  simple  salicylic  gauze  for  dry  dressings,  fulfil  most  of 
the  indications,  and  are  comparatively  safe.  The  covering  of  large 
granulating  surfaces  with  skin  can  be  hastened  by  the  Thiersch 
method  of  skin-transplantation.  This,  as  well  as  the  method  of  trans- 
planting large  skin-flaps  with  pedicles,  constitutes  the  best  method 
of  preventing  cicatricial  deformities  resulting  from  contractures  or 
adhesions.  If  these  have  occurred,  they  should  be  treated  by  excision 
of  the  cicatrix  and  closure  of  the  defect  by  one  of  the  above-mentioned 
methods  of  skin-grafting. 

In  very  extensive  burns  involving  a  large  portion  of  the  body  atten- 
tion to  the  general  condition  is  demanded.  Here  supporting  measures 
and  remedies  designed  to  relieve  pain  form  necessary  adjuvants  to  the 
local  treatment.  Profound  collapse  may  occur,  and  should  be  met  by 
the  administration  of  hot  alcoholic  drinks,  black  coffee,  etc.  The 
patient  is  to  be  wrapped  in  warm  blankets,  and  morphin  given  hypo- 
dermically  to  allay  pain  and  restlessness.  Autotransfusion  (envelop- 
ing the  limbs  in  elastic  bandages  to  drive  more  blood  to  the  heart) 
may  be  useful.     Subcutaneous  salt  infusion  has  been  recommended. 


X-RAY  BURNS. 

Certain  changes  are  produced  in  the  skin  by  exposure  to  an 
excited  vacuum  tube,  particularly  a  so-called  "  soft  tube  "  or  one  of 
low  resistance,  to  which  the  term  "  x-ray  burn  "  has  been  applied. 
While  there  may  be  some  doubt  as  to  the  propriety  of  calling  these 
lesions  burns,  yet  they  are  almost  universally  known  by  this  term,  and 
it  is  therefore  retained  in  this  connection. 


X-RAY  BURNS.  115 

The  changes  under  consideration  vary  with  the  length  and  intensity 
of  the  exposure.  According  to  Jutassy,1  hyperemia  only  may  result 
from  short  and  weak  exposures,  while  long  and  intense  exposures  are 
followed  by  ulceration.  The  lesions  may  assume  any  grade  of  severity 
of  dermatitis  between  these  two  extremes. 

The  striking  and  peculiar  feature  of  the  more  severe  lesions  consists 
of  disturbances  of  the  structure  of  the  blood-vessels  themselves,  the 
necrosis  arising  from  x-ray  burns  differing  in  this  respect  from  that 
arising  from  other  causes  (Gassman).  The  walls  of  the  arterioles  and 
veins  are  the  seat  of  a  deposit  of  fibrous  tissue,  whereby  appreciable 
thickening  and  corresponding  narrowing  of  the  lumen  of  the  vessels 
are  produced.  The  degenerative  process  extends  to  the  deeper  vessels 
as  well  as  to  those  peripherally  situated,  and  the  resulting  destructive 
lesion  corresponds  to  the  area  of  distribution  of  the  affected  blood- 
vessels. In  addition  to  the  mechanical  disturbances  incident  to  the 
narrowing  of  the  blood-vessels  from  fibrous  deposits,  and  the  resulting 
obliteration  of  the  capillaries,  the  results  of  irritation  of  the  peripheral 
sensor}7  nerves,  with  impairment  of  the  vasomotor  system  of  the  affected 
areas,  and  secondary  contraction  of  arterioles  and  consequent  impair- 
ment of  cell-nutrition,  are  not  to  be  ignored.  Further,  Destot  attrib- 
utes the  pathologic  changes  to  trophoneurotic  influences.  Bordier, 
in  experiments  upon  plants  and  animals,  found  that  exposure  to  the 
x-rays  inhibited  osmosis  ;  and  he  attributed  the  changes  in  the  tissues 
to  disturbances  of  nutrition  due  to  this  cause.  Finally,  Howlett,  and 
later  Judd,  claim  that  these  injuries  arise  from  the  action  of  currents 
generated  in  the  tissue  by  induction  from  the  tube — an  electrolysis  of 
the  parts. 

Symptoms. — The  necrosis  usually  commences  in  the  center  of  the 
affected  area,  and  extends,  through  persistent  although  almost  imper- 
ceptible progression,  toward  the  periphery.  The  progress  made  is 
generally  remarkable  for  its  slowness.  Unna's  observations  upon  a 
case  of  x-ray  dermatitis  erythematosa  led  to  the  belief  that  the  x-rays 
attacked  the  most  resistant  tissues  of  the  skin,  thus  explaining  the  long- 
continuing  cumulative  action. 

Other  histological  changes  include  atrophy  of  the  glandular  struc- 
tures of  the  skin  and  of  the  papillae  of  the  hair. 

The  effect  of  the  exposure  to  the  x-ray  tube  does  not  manifest  itself 
at  once,  as  a  rule,  the  average  time  being  about  one  week.  In  Gass- 
man and  Schenkel's  case  a  progressive  gangrene  appeared  four  weeks 
after  the  exposure.  The  course  of  the  lesions  may  be  acute,  subacute, 
or  chronic.  A  simple  x-ray  dermatitis  may  heal  comparatively  quickly, 
while  a  necrobiosis  penetrating  deep  into  the  tissues  will  be  healed  only 
with  great  difficulty. 

The  development  of  the  lesion  may  be  characterized  by  lancinating 
pains,  sensations  of  heat  and  cold,  anesthesia  or  hyperesthesia.  Patients 
with  x-ray  burns  will  sometimes  recall  that  a  pricking  sensation  was 
felt  during  the  examination.  A  simple  erythematous  blush  or  a  de- 
cided dermatitis  makes  its  appearance.  In  cases  that  go  on  to  mor- 
tification a  red  spot  appears  surrounded  by  macules,  vesicules,  or  pus- 

1  Fortschritte  a.  Geo.  d.  Roentgens?)-.,  B.  III.  H.  3. 


Il6  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

tules.  Destruction  of  tissue  is  manifested  by  the  appearance  of  a  black 
slough,  which  may  be  superficial,  but  which  mure  often  involves  the 
subcutaneous  connective  tissue. 

Tissues  in  which  the  vital  resistance  is  lessened  by  injury  are  more 
susceptible  to  the  deleterious  effects  of  the  x-ray.  The  lesions  are  more 
or  less  painful,  and  the  process  of  healing  is  very  slow.  They  are  most 
apt  to  follow  prolonged  exposure  on  successive  days,  the  tube  being 
brought  close  to  the  skin. 

In  the  prevention  of  x-ray  injuries  care  should  be  taken  to  place 
the  vacuum  tube  2  or  3  feet  away  from  the  patient  when  the  fluores- 
cent screen  is  used,  and  3  feet  or  more  from  the  plate  in  taking  x-ray 
pictures.  Tesla  suggests  that  an  aluminum  screen  be  interposed  be- 
tween the  tube  and  the  patient,  this  being  grounded  by  being  con- 
nected by  means  of  a  wire  to  the  gas-pipe. 

The  treatment  consists  of  absolute  rest,  cleanliness,  massage,  and 
constitutional  support.  Excision  of  the  gangrenous  area  and  skin- 
grafting  may  be  necessary. 


EFFECTS  OF  LIGHTNING. 

Lightning-stroke  is  the  passage  of  an  aerial  current  of  electricity 
through  the  body.  It  may  be  direct,  as,  for  instance,  when  the  body 
receives  the  direct  electrical  discharge ;  or  indirect,  when  air-induced 
electrical  shock  occurs  in  the  body,  direct  discharge  being  received  by 
some  contiguous  object,  as  a  tree. 

The  accident  occurs  with  greater  frequency  in  sparsely-settled  dis- 
tricts and  where  there  are  comparatively  few  objects,  such  as  trees, 
tall  buildings,  etc.,  which  serve  to  convey  the  electrical  currents  in  the 
atmosphere  to  the  earth  in  divided  portions  rather  than  in  an  accumu- 
lated discharge.  The  great  majority  of  individuals  affected  are  struck 
while  at  work  in  the  open  fields,  although  it  may  happen  at  sea,  and 
even  to  divers  at  work  beneath  the  water.  The  annual  loss  of  life 
throughout  the  world  from  lightning-stroke  is  very  great. 

Those  subjected  to  direct  lightning-stroke  perish  almost  imme- 
diately, in  the  vast  majority  of  cases.  Including  all  cases,  both  direct 
and  indirect,  72  per  cent,  prove  fatal. 

The  effects  of  lightning  upon  the  organism  differ,  according  to 
whether  the  purely  electrical  or  the  burning  action  predominates.  In 
direct  stroke  the  effects  are  sometimes  most  extraordinary.  In  addi- 
tion to  the  burning,  which  may  vary  from  a  simple  drying  of  the  epi- 
dermis to  extensive  and  deep  burns,  there  may  be  a  tearing,  lacerating 
action,  which  sometimes  produces  the  most  terrible  destruction,  such 
as  the  rupture  of  large  vessels,  and  even  the  complete  severing  of  a 
limb  from  the  body.  There  is  also  paralysis  of  respiration  and  circu- 
lation. In  some  instances  of  indirect  stroke  the  effect  is  similar  to 
that  produced  by  exposure  to  the  current  from  a  dynamo.  For  a 
given  individual  in  a  normal  condition  of  health  a  definite  amount  of 
electrical  energy,  of  whatever  kind  it  be,  will  produce  fatal  results. 
The  infliction  of  a  violent  electric  shock  upon  the  nerve-centers  gov- 
erning respiration  results  in  a  suspension  of  the  latter,  just  as  in  ex- 
treme cerebral  concussion.     In  addition  to  this  the  effect  of  the  elec- 


EFFECTS   OF  LIGHTNING. 


II" 


tricity  is  to  contract  the  arteries  and  increase  the  blood-pressure. 
Experiments  made  upon  dogs  seem  to  show  that  the  mere  passage 
of  a  current  sufficient  to  cause  death  does  not  produce  any  anatom- 
ical disintegration  (Bleile).  Certain  edematous  and  elevated  branching 
lines  of  a  brownish-red  color  are  sometimes  observed  diverging  in  a 
zigzag  direction  from  the  point  where  the  current  is  supposed  to  have 
entered  the  body,  constituting  the  so-called  lightning-marks  (Fig.  31). 


Fig.  31. — Lightning-marks. 

These,  according  to  Rollet,  are  the  result  of  the  setting  free  of  the 
coloring  matter  from  the  red  blood-corpuscles  in  the  line  of  the  light- 
ning-stroke, the  coloring  matter  transuding  through  the  walls  of  the 
vessels  and  their  branches. 

Symptoms. — When  the  lightning-stroke  is  not  immediately  fatal, 
the  patient  suffers  all  the  phenomena  of  profound  shock.  Semi-un- 
consciousness, or  even  profound  coma,  may  last  from  a  few  hours  to 
several  days.  Localized  anesthesia,  paralysis,  dysphagia,  disturbances 
of  vision,  and  other  nervous  phenomena  are  observed.  These,  with 
the  exception  of  the  visual  symptoms,  are  usually  transitory.  Light- 
ning-paralysis is  generally  recovered  from  in  a  few  days  or  weeks,  save 
when  the  paralysis  is  only  indirectly  due  to  the  lightning-stroke,  the 
direct  cause  being  a  hemorrhage  into  the  brain  or  spinal  cord.  The 
first  stage  of  lightning-paralysis  is  characterized  by  direct  injury  to  the 
nerves  or  muscles ;  in  the  second  stage  there  are  present  the  conditions 
of  a  traumatic  neurosis.  In  cases  which  eventually  prove  fatal,  death 
results  from  cerebral  hemorrhagic  or  other  effusion,  from  hemorrhage 
from  ruptured  vessels  elsewhere  than  in  the  brain,  from  the  shock  of 
the  severe  injuries  sustained,  or  from  the  ultimate  effects  of  the  injuries. 


Il8  INTERNATIONAL     TEXT-BOOK  OF  SURGERY. 

Treatment. — The  constitutional  symptoms,  shock,  etc.,  of  light- 
ning are  to  be  treated  symptomatically.  Such  stimulating  measures 
as  hypodermic  injections  of  strychnin,  small  doses  of  morphin,  strong 
coffee,  either  per  os  or  per  rectum,  should  be  employed. 

SHOCK. 

Syncope  and  Collapse. — The  terms  syncope  and  collapse  repre- 
sent conditions  which,  surgically  considered,  are  generally  more  or  less 
allied.  For  convenience  of  study,  as  well  as  for  all  practical  purposes, 
syncope,  with  its  fainting,  pallor,  and  temporary  unconsciousness,  may 
be  considered  as  the  first,  and  collapse,  with  its  extreme  impairment  of 
all  the  vital  processes  occurring  as  the  precursor  of  death,  may  be 
considered  as  the  last  stage  of  the  condition  known  as  shock.  The 
condition  of  syncope  may  be  so  profound,  however,  that  consciousness 
is  not  regained,  the  patient  passing  directly  into  the  stage  of  collapse 
without  the  occurrence  of  the  intermediate  stage. 

Shock. — Shock  is  a  peculiar  state  of  reflex  depression  of  the  vital 
functions,  especially  of  the  circulation.  It  is  suddenly  developed,  as  a 
rule,  and  is  due  to  nervous  exhaustion  resulting  from  severe  irrita- 
tion of  the  peripheral  ends  of  sensory  and  sympathetic  nerves  follow- 
ing an  injury.  The  condition  is  essentially  one  of  inhibition  of  nerve- 
force  and  reflex  paralysis.  There  is  apparently  exhaustion  of  the 
medulla  oblongata  and  spinal  cord,  followed  by  marked  lowering  of 
the  vital  powers.  Goltz's  experiments  show  that  paralysis  of  the  vaso- 
motor centers  in  the  medulla  is  the  essential  feature,  and  that  this  is 
produced  in  a  reflex  manner  by  violent  disturbances  of  the  sensory 
nerves.  Mechanical  irritation  or  stimulation  of  the  sensory  nerves 
temporarily  lessens  the  activity  of  the  corresponding  nerve-centers, 
which  become,  according  to  the  extent  of  the  irritation  and  degree  of 
the  reflex,  either  altered,  weakened,  or  paralyzed.  The  varying  degrees 
of  shock,  therefore,  are  dependent  upon  the  severity  of  the  irritation, 
as  well  as  upon  the  length  of  time  which  this  continues  in  existence. 
These  degrees  may  range  from  a  mere  temporary  faintness  from  anemia 
of  the  brain,  lasting  only  a  few  moments  (syncope),  to  a  profound,  con- 
tinued, and  finally  fatal,  suspension  of  function  or  vital  depression 
(collapse). 

With  diminution  or  paralysis  of  the  vascular  tone,  particularly  in 
the  arteries,  and  the  coincident  weakness  of  the  heart's  action,  the 
blood  is  unequally  distributed,  and  the  circulatory  balance  is  disturbed. 
The  veins,  particularly  those  of  the  abdomen,  become  overfilled  from 
gravitation,  the  right  side  of  the  heart  becomes  gradually  distended, 
and  the  quantity  of  blood  in  the  arteries  is  correspondingly  lessened. 
As  a  result  of  this  the  lungs  and  brain  suffer  from  anemia,  and,  in  the 
event  of  the  condition  persisting,  the  heart's  action  ceases. 

The  conditions  of  pain,  fear,  and  shock,  though  apparently  widely 
different,  have  much  in  common.  The  same  pupillary,  respiratory, 
voluntary  motor,  cardiomuscular,  nutritive,  and  psychical  phenomena, 
are  common  to  all  three. 

In  addition  to  the  above  condition,  which  is  spoken  of  as  corporeal 
shock,  there  is  another  form,  in  which  the  depression  is  due  to  emo- 


SHOCK.  I  19 

tional  causes,  and  which  is  known  as  psychic  shock.  Finally,  both 
may  be  combined  in  a  case  of  shock. 

Symptoms. — These  may  supervene  almost  immediately  upon  the 
reception  of  an  injury,  or  toward  the  close  of  an  operation.  In  the 
latter  case  they  may  either  make  their  first  appearance  upon  the  occur- 
rence of  a  sudden  or  large  loss  of  blood,  or  else  the  symptoms  may 
come  on  insidiously  (delayed  shock).  The  characteristic  symptoms 
are  pallor  of  the  skin  and  visible  mucous  membranes  ;  loss  of  facial 
expression  ;  eyes  dull  and  pupils  dilated,  only  slowly  reacting  to  light ; 
head  bathed  in  a  cold  perspiration  ;  complete  muscular  relaxation ; 
feeble,  irregular,  and  sighing  respirations ;  delayed,  irregular,  and 
weakened  heart-action  ;  diminished  sensibility,  the  patient  ceasing  to 
complain  of  pain,  and  sometimes  semi-unconsciousness ;  coldness  of 
the  expired  breath  and  of  the  surface  of  the  body ;  subnormal  body- 
temperature  ;  and  mental  torpor.  Occasionally  nausea  and  vomiting 
are  observed. 

The  above  symptoms  are  present  in  the  majority  of  cases,  and  con- 
stitute what  is  known  as  the  apathetic  or  torpid  form  of  shock.  The 
mental  torpor  is  sometimes  replaced  by  a  more  active  train  of  symp- 
toms. Under  these  circumstances  the  patient  is  excited  and  restless, 
tossing  himself  around  in  the  bed,  and  shrieking  and  crying  out  in 
maniacal  delirium.  During  all  this  time  he  may  have  a  thready  or 
almost  imperceptible  pulse,  and  irregular,  shallow  respirations. 

The  pallor  and  coldness  of  the  surface  in  shock  are  due  to  altera- 
tions in  nutrition  which  depend,  in  their  turn,  upon  trophic  disturb- 
ances. The  arrest  of  tissue-metamorphosis  leads  to  respiratory  disturb- 
ances, the  blood,  through  loss  of  its  nourishing  properties,  being  no 
longer  capable  of  properly  stimulating  the  respiratory  centers.  Reflex 
mydriasis  is  always  present  in  any  painful  irritation,  and  is  due  to  over- 
stimulation of  the  sensitive  nerves.  The  muscular  relaxation,  or  weak- 
ness of  the  voluntary  muscular  system,  is  due  to  inhibition  of  the 
motor  centers  following  peripheral  irritation,  and  is  analogous  to  the 
arrest  of  the  respiratory  muscles  on  the  affected  side  in  pleuropneu- 
monia (Likorsky).  The  cardiomuscular  symptoms  emphasize  the 
peculiar  and  especial  sensitiveness  of  the  vasomotors.  Vascular  spasm 
is  soon  followed  by  vasomotor  paralysis.  A  fall  of  blood-pressure  and 
diminution  of  the  number  and  strength  of  the  heart-pulsations  follow. 
The  mental  apathy  is  due  to  the  depression  of  the  psychical,  as  the 
other  symptoms  to  that  of  the  physiological,  functions. 

In  the  cases  in  which  the  supposed  shock  comes  on  more  gradu- 
ally, the  symptoms  may  really  be  due  to  hemorrhage.  The  condition 
of  delayed  shock  is  said  to  occur  in  cases  in  which  the  patient  was  ex- 
posed to  great  danger,  and  yet  escaped  with  slight  physical  harm.  The 
patient  may  give  a  history  of  being  able  to  move  about  at  first  without 
much  difficulty,  the  shock  supervening  insidiously.  Symptoms  due  to 
delayed  shock  are  rarely,  if  ever,  observed  following  operative  proced- 
ures. They  do,  however,  occur  rather  frequently  following  railroad 
accidents,  and  form  a  basis  for  some  of  the  cases  of  so-called 
traumatic  neuroses  which  often  constitute  part  of  the  contention  in 
suits  to  recover  damages  for  personal  injuries.     In  this  class  of  cases 


120  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

there  is  frequently  room  for  suspicion  of  exaggeration,  if  not  of  down- 
right simulation. 

The  condition  of  shock  may  persist  for  from  two  to  twenty-four 
hours.  The  stage  of  reaction  is  announced  by  improvement  in  the 
pulse,  both  as  regards  its  rapidity  and  strength,  and  a  more  or  less 
pronounced  rise  in  temperature.  Should  the  latter  exceed  the  normal, 
as  it  frequently  does,  it  will  soon  fall  again.  The  formerly  much 
dreaded  "  excessive  reaction  "  following  the  shock  of  operation  is  now 
known  to  be  due  to  septic  inflammatory  conditions,  and  is  rarely  en- 
countered, comparatively  speaking.  The  recovery,  in  uncomplicated 
cases  of  shock,  is  usually  rapid.  In  the  course  of  a  few  hours  the  im- 
provement is  so  pronounced  that  danger  from  this  source  is  no  longer 
to  be  feared.  Mental  symptoms,  however,  sometimes  persist  for  a 
longer  or  shorter  time ;  though  perfect  recovery  takes  place  eventu- 
ally. 

In  cases  complicated  with  large  losses  of  blood  and  severe  injuries 
to  important  parts,  particularly  the  brain,  as  well  as  cases  of  prolonged 
and  severe  operative  procedures  involving  vital  organs,  the  condition 
of  shock  may  pass  into  that  of  collapse  and  end  in  death.  Tempera- 
ture observations  should  be  carefully  made.  If  the  fall  of  temperature 
following  an  operation  is  but  one  degree  or  less,  recovery  will  probably 
ensue  ;  if  three  or  more  degrees,  a  fatal  result  may  be  expected. 

Diagnosis. — As  between  corporeal  and  psychic  shock  the  history 
of  the  case  will  establish  the  diagnosis.  Shock  from  purely  emotional 
causes  is  rarely  so  profound  and  prolonged  as  to  involve  danger  to  life. 
Those  more  common  nervous  conditions  involving  manifestations  of 
extreme  fright,  as  well  as  those  symptoms  which  occur  from  dangerous 
chloroform  or  ether  narcosis  or  which  follow  severe  hemorrhage,  are 
to  be  carefully  differentiated  from  true  shock. 

Shock  should  be  carefully  diagnosed  from  fat-embolism.  Its  oc- 
currence immediately  after  the  injury,  as  a  rule,  as  compared  to  the 
period  at  which  the  symptoms  of  fat-embolism  make  their  appearance — 
namely,  from  thirty-six  hours  to  three  days,  will  serve  to  differentiate 
the  two  conditions. 

Treatment  of  Shock. — As  a  routine  measure  for  the  prevention 
of  post-operative  shock,  the  patient  should  be  kept  warm  in  bed  for 
several  hours  before  the  operation.  As  cardiac  stimulants  a  -^-grain 
dose  of  strychnin  and  3  grains  of  caffein  citrate  should  be  given  hypo- 
dermically  an  hour  beforehand,  as  a  part  of  the  routine  of  preparation. 
A  cup  of  hot,  strong  coffee  may  also  be  given  at  this  time  with  advan- 
tage, to  prevent  the  depressing  effects  of  the  ether.  Opium  by  the 
mouth,  or,  better  still,  morphin  hypodermically,  is  urged  by  some  as  a 
useful  preliminary  measure  to  fortify  the  heart  and  nervous  system. 
The  operating-room  should  be  warm,  and  the  operating-table  may  be 
heated  by  hot-water  bottles.  One  of  the  especially  constructed  tables 
designed  to  keep  up  artificial  heat  during  the  operation  may  be  em- 
ployed. 

Much  may  be  done  in  preventing  shock  by  the  method  of  conducting 
the  operation  itself.  The  tendency  of  modern  surgery,  with  its  many 
and  often  unnecessarily  elaborate  details  of  antiseptic  technic,  is  to 
encourage  the  occurrence  of  shock.    The  employment  of  dry  sterilized 


SHOCK.  121 

towels  and  sheets  to  isolate  the  field  of  operation  rather  than  those 
wet  with  antiseptic  solutions,  is  to  be  preferred,  in  order  to  prevent  the 
undue  abstraction  of  heat.  For  the  same  reason  dry  methods  of  oper- 
ating, and  the  avoidance  of  irrigation  as  much  as  possible,  should  be 
insisted  upon.  The  trunk  in  particular  is  to  be  protected  against  chilling, 
only  a  sufficient  portion  being  exposed  for  the  purpose  of  the  opera- 
tion. The  lower  extremities,  when  not  the  object  of  operative  attack, 
should  be  covered  with  warm  stockings  and  drawers  or  bandaged  with 
cotton  wadding  and  flannel  rollers.  Prolonged  exposures  of  such  or- 
gans as  the  brain  or  intestines  will  serve  to  induce  shock.  During  all 
long  operations,  the  employment  of  a  hot  stimulating  enema  (whiskey 
and  water)  is  advisable,  without  waiting  for  the  development  of  symp- 
toms of  shock.  With  the  perfect  system  of  installation  and  organization 
which  marks  the  modern  well-equipped  hospital,  and  that  simplification 
of  operative  technic  which  aims  to  accomplish  the  desired  object  in 
the  shortest  possible  space  of  time,  the  precision  of  the  surgery  of 
to-day  may  be  so  combined  with  the  speed  which  characterized  the 
surgery  of  the  past  generation,  that  post-operative  shock  will  be  as 
rare  an  occurrence  as  post-operative  sepsis. 

If  there  is  especial  reason  to  fear  the  supervention  of  dangerous 
shock  in  any  given  case  of  contemplated  operation,  the  suggestion  of 
Professor  Stephen  Smith  may  be  followed  of  stimulating  the  patient 
for  several  hours  beforehand  by  means  of  hot  alcoholic  drinks.  An 
ounce  of  brandy  or  whiskey  is  to  be  given  in  a  glass  of  hot  milk  ten 
hours  before  the  time  appointed  for  the  operation,  and  repeated  two  or 
three  times  at  intervals  of  two  hours,  unless  symptoms  of  intoxication 
appear.  The  method  of  storing  blood  in  the  extremities  by  the  pre- 
liminary application  of  a  tourniquet,  with  the  view  of  permitting  the 
blood  to  escape  into  the  general  circulation  in  an  emergency  during 
the  operation,  although  of  service  in  cases  of  hemorrhage  and  in  dan- 
gerous chloroform  narcosis,  is  of  doubtful  utility  as  a  preventive  of 
shock. 

When  the  conditions  of  extreme  shock  are  present  following  an  in- 
jury, the  administration  of  an  anesthetic  is  contraindicated.  The  effect 
of  the  anesthetic  may  be  sufficient  to  stop  completely  the  pulsations 
of  an  already  weakened  heart-action.  Whatever  operative  procedure 
is  absolutely  necessary,  as,  for  instance,  for  arrest  of  hemorrhage,  should 
be  carried  out  without  an  anesthetic. 

In  the  treatment  of  shock  the  patient  should  be  laid  flat  upon  his 
back  and  the  entire  body  tilted,  head  downward,  to  a  decided  angle. 
Should  venous  congestion  of  the  face  occur  while  the  patient  is  in  this 
position,  the  latter  may  be  modified,  or  the  body  placed  upon  a  level  if 
necessary.  Blood  should  be  forced  into  the  more  vital  parts  by  rub- 
bing-movements in  the  direction  of  the  trunk.  Dry  heat  is  to  be 
applied,  but  caution  should  be  observed  not  to  expose  the  patient  to 
the  danger  of  burns.  Sinapisms  may  be  applied  to  the  extremities; 
but  should  be  used  cautiously,  for  the  reason  that  over-stimulation  of 
the  peripheral-nerve  distribution  may  result  in  increasing  the  shock. 
Cloths  wrung  out  of  hot  mustard  water  may  be  applied  to  the  precor- 
dial region.  If  the  patient  can  swallow,  warm  stimulating  drinks  should 
be  given — strong  coffee,  wine,  or  whiskey  and  water,  as  hot  as  can  be 


122  INTERNA  TIONA  L    TEX  T-  B  O  OK '   OF  SI  TR  G  E  A'  Y. 

taken.  If  he  is  unable  to  swallow,  or  there  is  risk  of  the  fluids  passing 
into  the  larynx,  these  should  be  given  by  enema.  An  enema  consisting 
of  an  ounce  of  whiskey,  from  3  to  6  grains  of  musk,  and  15  or  20  drops 
of  tincture  of  opium,  added  to  a  cup  of  strong  coffee  and  thrown  into 
the  rectum  is  of  great  value.  In  the  meanwhile,  available  remedies  de- 
signed to  stimulate  the  heart's  action  and  the  respiratory  centers  are  to 
be  given  hypodermically.  Of  these  the  most  valuable  are  strychnin 
and  atropin.  The  former  may  be  given  in  ■£$-,  or  even  y^-grain,  and 
the  latter  in  ^L-grain  doses.  Camphor  dissolved  in  ether  and  extract 
of  calabar  bean  are  also  recommended.  Nitroglycerin  in  T^-grain 
doses  hypodermically  and  inhalations  of  amyl  nitrite,  particularly  the 
latter,  are  stated,  upon  theoretical  grounds,  to  aid  in  the  relief  of  the 
vasomotor  spasm  of  the  cerebral  capillaries.  The  dose  of  amyl  nitrite 
by  inhalation  can  scarcely  be  accurately  regulated,  but  a  few  drops  may 
be  placed  upon  the  corner  of  a  napkin  and  inhaled.  If  marked  flush- 
ing of  the  face  occurs  the  remedy  is  said  to  have  accomplished  its 
object.  I  have  never  observed  marked  evidences  of  benefit  from  the 
use  of  this  drug.  The  fumes  of  strong  ammonia  are  to  be  employed 
with  caution. 

Tincture  of  digitalis  is  to  be  given  by  the  mouth  in  10-drop  doses, 
whenever  possible.  The  patient  can  usually  take  care  of  it,  if  it  be 
administered  drop  by  drop  upon  the  back  of  the  tongue  and  allowed 
to  trickle  down  the  throat.  In  the  event  of  failure  to  administer  it  in 
this  way,  it  may  be  given  hypodermically,  after  dilution  (1  to  4  parts) 
with  whiskey. 

In  the  employment  of  these  powerful  drugs  the  possibility  of  their 
failure  to  act  for  a  certain  length  of  time,  after  which  a  cumulative 
effect  may  result,  should  be  borne  in  mind  to  the  end  that  caution  be 
exercised  not  to  repeat  the  dosage  too  often  or  at  too  short  intervals. 
In  this  connection  the  experiments  of  Roger  are  interesting.  This 
observer  produced  the  condition  of  shock  in  frogs  by  means  of  the 
discharge  from  a  Leyden  jar,  and  noted  the  interesting  fact  that  the 
spinal  cord  and  muscular  apparatus  became  insensitive  to  the  stimuli 
which  affect  these  structures  ordinarily,  as,  for  instance,  strychnin  in 
the  case  of  the  spinal  cord,  and  veratrin  in  that  of  the  muscles.  Either 
the  tissues  are  unable  to  react,  which  can  scarcely  be  true  of  the  mus- 
cles, or,  more  probably,  the  stimulating  agent  does  not  pass  from  the 
blood  to  the  tissues.  Failure  of  absorption  cannot  explain  it,  since  the 
agents  are  found  circulating  with  the  blood.  These  observations 
throw  some  light  upon  the  well-known  fact  that  powerful  stimulating 
remedies  frequently  fail  to  act  in  the  presence  of  profound  shock. 
With  the  subsidence  of  the  conditions  which  prevent  them  from  acting, 
the  drugs,  after  repeated  administration  of  the  usual  remedial  dose, 
may  exert  a  toxic   effect. 

If  death  threatens  from  failure  of  the  respiratory  act,  in  addition  to 
hypodermic  injections  of  atropin,  artificial  respiration  may  be  practised. 
In  addition  to  this  the  phrenic  nerve  may  be  subjected  to  faradization, 
one  pole  of  the  induction  coil  being  applied  over  the  phrenic  nerve  at 
the  root  of  the  neck,  and  the  other  at  the  diaphragm. 

In  cases  of  the  so-called  erethistic  or  restless  type,  in  addition  to 
the  employment  of  the   usual   remedial   measures,  the  administration 


FA  T-EMB  OL  ISM.  1 2  3 

of  morphia  in  ^--grain  doses  will  be  of  great  value.  Undue  and  sud- 
den reaction  is  sometimes  observed  in  this  class  of  cases,  and  should 
be  carefully  guarded  against. 

Intravenous  saline  infusions,  according  to  Crile,  cause  an  increase  in 
the  venous  pressure  in  the  vena  cava,  the  filling  of  the  chambers  of 
the  heart  being  followed  by  an  increase  in  the  force  of  the  contractions 
and  by  a  rise  of  the  blood  pressure  generally.  In  regulating  the 
quantity  to  be  employed  for  shock  following  an  operation,  the  surgeon 
is  to  be  guided  by  the  effect  upon  the  pulse,  smaller  quantities  being 
employed,  and  repeated,  if  necessary,  as  required.  The  value  of  these 
injections  is  wholly  mechanical.  In  Crile's  experiments  quantities  up 
to  twice  the  amount  of  blood  calculated  to  be  present  in  the  animal 
were  given  before  the  increased  blood-pressure  was  sustained.  The 
continued  use  of  small  and  frequently  repeated  doses  of  strychnin 
given  hypodermatically,  and  of  intravenous  or  intracellular  infusions 
of  saline  solution,  is  most  effectual.  Over-stimulation  is  followed  by 
a  greater  depression,  and  gives  rise  to  hemorrhage  from  the  operation 
wound,  or  from  the  site  of  separated  adhesions  in  abdominal  opera- 
tions. 

FAT-EMBOLISM. 

During  life  the  fat-globules  of  the  body  represent  a  drop  of  oil  en- 
closed in  a  vesicle.  Under  the  circumstances  of  an  extensive  crushing 
injury  a  certain  amount  of  fat  may  enter  the  circulation  through  veins 
which  are  coincidently  injured,  or  by  absorption  of  the  lymph-chan- 
nels. The  fat,  in  the  great  majority  of  cases,  is  the  medullar}-  sub- 
stance of  a  bone,  which  has  become  broken  up  in  connection  with 
multiple  fractures,  or  the  crushing  of  a  simple  large  bone.  The  fat 
may  also  be  supplied  by  the  subcutaneous  layer,  the  liver,  brain,  etc. 
Whatever  the  source,  the  condition  is  almost  always  due  to  traumatism. 
The  instances  in  which  it  has  its  origin  in  inflammatory  or  degenera- 
tive conditions  are  rare.  Osteomyelitis  is  said  to  produce  it.  Fat- 
embolism  is  more  apt  to  occur  in  injuries  to  bones  for  the  reason  that, 
not  only  is  there  a  large  amount  of  fat  in  the  medulla,  but  large  veins 
which  do  not  easily  collapse  are  also  present.  Fat-embolism  probably 
occurs  to  a  greater  or  less  extent  in  every  case  of  fracture,  and  in 
many  other  traumatisms  as  well — viz.,  lacerations  of  the  soft  parts, 
rupture  of  fatty  liver,  surgical  operative  procedures,  etc. 

Upon  entering  the  circulation  the  fat  is  first  carried  to  the  lungs, 
where  the  larger  part  of  it  remains.  A  portion  of  the  fat,  however, 
may  traverse  the  pulmonary  capillaries  and  be  arrested  in  the  brain, 
the  spinal  cord,  the  kidneys,  the  muscular  structure  of  the  heart,  and 
other  organs.  Blocking  of  the  capillary  circulation  in  the  lungs  may 
result  from  an  abundance  of  fat  and  from  high  arterial  pressure.  In 
the  case  of  the  kidneys  the  fat  passes  into  the  capillaries  of  the  glo- 
meruli and  is  excreted  by  the  urine.  The  fat  may  likewise  be  found 
in  the  bile.  Small  ecchymotic  hemorrhages  in  the  liver  and  brain  are 
sometimes  found  post-mortem.  Occlusion  of  the  blood-vessels  of  the 
myocardium  by  the  fat  results  in  a  fatty  degeneration  which  sometimes 
may  be  detected  macroscopically  in  the  shape  of  dull  spots. 

Symptoms. — The  symptoms  of  fat-embolism  may  appear  as  early 


124  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

as  thirty-six  hours  after  the  injury  (Park),  or  they  may  be  postponed 
to  the  fifth  day.  The  countenance  is  at  first  pale,  and  the  facial  ex- 
pression anxious.  The  arrest  of  fat  in  the  pulmonary  circulation  pro- 
duces dyspnea  and  rapid  breathing,  and  finally  cyanosis.  This  may 
be  associated  with  Cheyne-Stokes  respiration,  with  muscular  twitch- 
ings,  and  paralysis  of  certain  muscles  suggesting  cerebral  edema  as  a 
complication.  Symptoms  of  edema  of  the  lungs  are  present,  and  in 
some  instances  foam  tinged  with  blood  issues  from  the  mouth. 
Hemoptysis  is  only  of  occasional  occurrence.  The  heart's  action  is 
increased  and  becomes  irregular,  and  there  may  be  a  rise  of  temper- 
ature, but  this  is  not  characteristic.  There  is  usually  at  first  mental 
excitement,  but  this  soon  gives  place  to  somnolency,  and,  in  fatal  cases, 
to  coma.     Fat-globules  are  found  in  the  urine. 

Diagnosis. — This  condition  will  be  suspected  if  the  group  of 
symptoms  described  comes  on  after  any  injury  involving  the  bony 
structures,  and  perhaps  in  other  extensive  injuries  as  well.  The  symp- 
toms should  not  be  mistaken  for  shock  following  fracture,  nor  for  pul- 
monary embolism.  The  time  of  the  occurrence  of  the  symptoms  will 
aid  in  the  differential  diagnosis.  The  shock  following  a  fracture  usually 
develops  within  the  first  three  hours,  and  is  rarely  delayed  beyond  this 
time;  fat-embolism  may  occur  in  exceptional  instances  as  early  as 
thirty-six  hours,  but  as  a  rule  it  is  delayed  for  three  days  ;  pulmonary 
embolism  is  an  occasional  complication  of  fracture  occurring  in  the 
third  week,  and  depends  upon  the  displacement  of  a  portion  of  a 
thrombus  following  injury  to  a  vein,  the  loosened  portion  migrating 
to  the  lung  and  causing  death  by  obstructing  the  pulmonary  artery. 
In  general  terms,  therefore,  the  time  for  the  occurrence  of  these  com- 
plicating sequelae  in  fractures  is,  for  shock  three  hours,  for  fat-embol- 
ism three  days,  and  for  pulmonary  embolism  three  weeks  (Dennis). 
Exceptionally,  the  supply  of  fat  may  be  intermittent  and  occur  at  dif- 
ferent stages  of  the  repair  (Heuter-Lossen). 

The  elimination  of  the  fat  by  the  urine  after  being  forced  through 
the  lungs  and  carried  thence  to  the  kidneys  forms  the  basis  for  the 
most  valuable  diagnostic  point  in  this  condition.  The  fat  is  found 
floating  upon  the  surface  of  the  urine  in  the  shape  of  oil-like  drops. 
In  doubtful  cases  in  which  the  symptoms  are  cerebral  and  cardiac 
rather  than  markedly  pulmonary  in  character,  the  discovery  of  fat  in 
the  urine  is  positive  evidence  of  fat-embolism.  In  cases  in  which  the 
classical  symptoms  of  difficult  respiration  and  embarrassed  heart-action 
are  present,  the  presence  of  fat  in  the  urine  completes  the  clinical 
picture. 

Prognosis. — Although  fat-embolism  may  terminate  fatally,  death 
from  this  cause  alone  occurs  but  rarely.  Mech,1  however,  has  collected 
15  cases  in  which  every  other  cause  of  death  could  be  excluded. 
Experiments  made  upon  animals  show  that  an  amount  of  fat  equal  to 
three  times  that  contained  in  the  thigh,  slowly  injected,  is  necessary  to 
produce  death;  injected  rapidly  a  smaller  amount  suffices  (Ribbert). 
Death  usually  takes  place  from  interference  with  the  circulation,  al- 
though Scriba  asserts  that  the  fatal  result  is  invariably  due  to  changes 
in  the  central  nervous  system.    The  cardiac  lesions  found  upon  autopsy 

1  Ribbert,  of  Zurich  :  Correspondenz-blatt  fur  schweizer  Aertze,  Basel,  August  I,  1894. 


THE  REPAIR    OF  SPECIAL    TISSUES.  1 25 

are  always  associated  with  pulmonary  and  cerebral  conditions  sufficient 
of  themselves  to  cause  death  ;  there  is  therefore  no  means  of  deter- 
mining whether  or  not  these  alone  are  competent  to  bring  about  a  fatal 
issue. 

Treatment. — The  first  indication  is  absolute  physiological  rest  of 
the  injured  parts,  to  prevent  further  breaking  up  and  dissemination  of 
fat.  This  must  be  secured  at  all  hazards,  forced  mechanical  restraint 
being  employed  if  the  patient's  state  demands  it,  as,  for  instance,  in 
conditions  of  delirium,  etc.  The  next  most  important  indication  re- 
lates to  the  stimulation  of  the  heart's  action,  in  order  that  the  fat  may 
be  forced  from  the  venous  to  the  arterial  system,  where  it  may  undergo 
either  oxygenation  or  saponification  through  the  medium  of  the  alka- 
line constituents  of  the  blood.  The  ordinary  cardiac  stimulants,  such 
as  alcohol,  digitalis,  and  strychnin,  are  to  be  employed.  In  addition  to 
these,  inhalations  of  oxygen  may  be.  useful  (Park).  Cupping  will  assist 
in  relieving  the  dyspnea.  The  administration  of  ether  in  the  form  of 
Hoffman's  anodyne,  or  its  use  by  hypodermic  injection,  is  suggested. 
Finally,  in  cases  in  which  there  is  extensive  comminution  of  bone, 
making  it  difficult  to  maintain  the  parts  at  perfect  rest,  continued  disin- 
tegration and  entrance  of  fat  into  the  circulation  may  constitute  a  vital 
indication  for  amputation. 

THE  REPAIR  OF  SPECIAL  TISSUES. 

The  Skin  and  Subcutaneous  Connective  Tissue. — Contu= 
sions. — Owing  to  the  great  elasticity  of  the  skin,  force  applied  to  its 
surface  by  a  blunt  object  may  produce  a  solution  of  continuity  of  the 
structures  beneath  without  separation  of  the  skin  itself.  These,  as 
well  as  crushing  effects,  may  also  lead  to  rupture  of  blood-vessels  and 
hemorrhage  into  the  subcutaneous  connective  tissue  (hematoma).  The 
presence  of  long  elastic  fibers  in  the  subcutaneous  connective  tissue 
will  account  for  this  power  of  resistance  to  injury  possessed  by  the  skin. 

The  arrangement  and  extent  of  these  fibers  are  not  the  same  in  all 
portions  of  the  surface  of  the  body,  but  tend  to  follow  the  direction  of 
the  muscles  of  a  part.  The  fibers  pursue  a  course  almost  parallel  with 
the  limb  in  the  extremities ;  upon  the  trunk  they  are  irregularly  dis- 
tributed as  regards  direction  ;  while  about  the  mouth  and  eyes  they 
follow  the  course  of  the  fibers  of  the  orbicular  muscles.  In  the 
patellar  region  and  about  the  olecranon  the  elastic  fibers  pass  in  a  con- 
centric direction. 

Wounds  of  the  Skin. — The  manner  in  which  wounds  of  the  skin 
will  gape  will  depend  upon  the  location  of  the  wound  and  the  direction 
in  which  it  divides  the  elastic  fibers.  The  maximum  amount  of  gaping 
occurs  when  the  wound  is  upon  an  extremity  and  passes  at  right  angles 
to  the  direction  of  these  fibers,  and  the  minimum  amount  when  it 
passes  in  the  same  direction  as  the  elastic  fibers,  so  that  but  few  of  the 
latter  are  divided.  The  proximity  of  the  wound  to  one  of  the  gingly- 
moid  or  hinge-like  joints  will  likewise  govern  the  amount  of  gaping. 
When  in  the  neighborhood  of  the  elbow-  or  knee-joint,  tension  upon 
the  convex  side  of  the  articulation  will  tend  to  increase  the  separation 
of  the  wound-edges.     In  the  sole  of  the  foot  and  palm  of  the  hand 


126  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

the  fibrous  structure  of  the  connective  tissue  is  so  arranged  as  to  form 
a  dense  attachment  between  the  papillary  body  and  the  underlying 
aponeurotic  structures,  and  hence  in  these  regions  wounds  gape  but 
very  slightly. 

Abrasions. — In  abrasions  of  the  skin  involving  but  little  more  than 
the  papillary  layer,  the  reparative  process  takes  place  readily  and  path- 
ological inflammation  does  not  occur.  The  injured  layer  of  the  rete 
Malpighii  furnishes  a  few  drops  of  blood  and  exudate,  which,  mingling 
together  and  undergoing  coagulation,  cling  to  the  abraded  surface. 
Evaporation  of  the  watery  constituents  leads  to  drying  of  the  mass, 
and  a  crust  or  scab  is  formed.  The  underlying  wounded  surface  is 
thus  protected ;  the  mass  itself  in  the  dry  state  presents  no  longer 
a  favorable  pabulum  for  bacteria,  and  suppuration  is  prevented. 

In  this  method  of  repair,  known  as  healing  under  the  scab,  there  is 
complete  development  of  the  epidermal  layer  beneath  the  incrustation, 
if  the  latter  is  permitted  to  fall  off  of  itself.  It  is  only  possible  in  a 
natural  way  when  there  is  but  a  slight  amount  of  primary-wound 
secretions,  and  in  situations  favorable  to  rapid  desiccation.  More  or 
less  successful  attempts  to  imitate  the  formation  of  the  scab  or  crust 
by  artificial  means  have  been  made  in  wounds  extending  into  the  sub- 
cutaneous connective  tissue  and  involving  blood-vessels  and  lymph- 
channels.  Hermetical  sealing  of  the  wound  by  means  of  collodion  or 
similar  substances,  asepsis  having  been  previously  assured  and  the 
wound-edges  brought  together,  is  often  quite  efficient.  Any  occlusive 
method  which  prevents  the  entrance  of  extraneous  matters  and  irrita- 
ting substances  imitates  the  process  of  healing  under  the  scab. 

Traumatic  Inflammation  of  the  Skin. — The  skin  may  take  on  sup- 
purative inflammation  from  infection  originating  in  the  skin.  The  in- 
flammation, however,  under  these  circumstances  is  superficial  in  char- 
acter and  comparatively  harmless,  involving  only  the  rete  Malpighii 
and  papillary  layer.  Rapidly-progressive  suppurative  inflammation  of 
the  skin  only,  owing  to  the  dense  character  of  the  parts  involved,  is 
exceedingly  rare  and  almost  impossible. 

Traumatic  Inflammation  of  the  Subcutaneous  Connective  Tissue. 
— Phlegmonous  inflammatory  conditions  of  a  very  severe  character 
are  easily  produced  in  the  subcutaneous  connective  tissue,  owing  to 
the  arrangement  of  the  elastic  fibers  in  this  situation,  and  to  the  fact 
that  the  lymph-current  runs  in  the  same  direction.  Phlegmonous  in- 
flammation of  the  subcutaneous  connective  tissue,  however,  does  not 
always  have  its  origin  in  a  palpable  wound  involving  this  structure. 
Bacteria  of  sufficient  infective  power,  which  have  gained  entrance  to 
the  rete  Malpighii  by  an  almost  microscopic  breach  of  surface,  may  there 
find  sufficient  pabulum  for  their  maintenance  so  as  to  reach  the  subcuta- 
neous connective  tissue  finally.  Here  they  propagate  rapidly  and  produce 
their  untoward  effects.  So-called  idiopathic  phlegmonous  inflamma- 
tions are  to  be  accounted  for  in  this  manner.  The  more  or  less  con- 
stant coexistence  of  lymphangitis  renders  it  probable  that  the  infection 
makes  its  way  along  the  lymph-channels.  Traumatic  erysipelas,  or 
erysipelatous  cellulitis,  is  said  to  be  present  where  the  papillary  layer 
and  rete  Malpighii  are  involved  simultaneously  with  the  subcutaneous 
connective  tissue  in  the  inflammatory  process. 


THE   REPAIR    OF  SPECIAL    TISSUES. 


127 


Loss  of  Substance. — This  may  occur  in  the  skin  either  as  the 
direct  result  of  trauma,  or  indirectly  from  sloughing  following  the  in- 
jury, and  from  the  presence  of  a  very  high  grade  of  phlegmonous 
inflammation  as  well.  Destructive  lesions  of  the  skin  likewise  follow 
as  an  effect  of  extreme  heat  and  cold  (burn  and  frost-bite),  and  from 
ulceration. 

In  the  repair  which  takes  place  the  first  essential  is  the  pro- 
liferation of  healthy  granulations.  By  a  process  of  contraction  these 
subsequently  approximate  to  some  extent  the  margins  of  the  granu- 
lating surface.  In  this  way  the  defect  is  partially  corrected  by  the 
neighboring  tissues,  but  these  in  their  turn  are  so  displaced  as  to  give 
rise  in  some  situations  to  very  serious  deformities. 

In  order  to  complete  the  process  of  repair,  in  addition  to  the 
attempt  at  closure  of  the  defect  by  cicatricial  shrinkage,  the  formation 
of  an  epidermal  layer  is  needed.  This  formation  may  take  place  rap- 
idly or  slowly.  The  resulting  epidermal  formation  when  completed 
may  be  a  firm  and  solid  layer,  or- it  may  be  found  to  be  thin  and  defec- 
tive, with  a  tendency  to  break  down  in  ulceration.  Under  these  latter 
circumstances  further  aid  may  be  needed.  This  aid  is  furnished  by 
plastic  procedures,  skin-transplantation,  etc.  (Reverdin,  Thiersch). 

The  Cicatrix. — The  complete  cicatrix  is  designed  to  serve  the  pur- 
poses of  the  normal  structure  which  it  replaces,  although  it  is  never 
identical  with  these  either  anatomically  or  functionally. 

Recently-formed  cicatricial  tissue  (Fig.  32)  may  break  down  and 
take   on   inflammatory   conditions,   particularly  if  aseptic   precautions 


Til     iw 

FlG.  32. — Cicatricial  tissue  ;  X  670. 


have  been  neglected  during  the  healing  process.  Abscesses  may  form 
in  scar-tissue  from  the  presence  of  bacteria,  as  well  as  foreign  bodies, 
such  as  bone-spiculse,  or  portions  of  ligature  or  suture-material. 
Ulcerative  conditions  in  the  recent  cicatrix  result  from  mechanical 
causes,  such  as  friction  from  the  clothing,  and  heal  readily;  later  on, 
however,  with  lessening  of  the  blood-supply,  they  heal  but  slowly. 

Owing  to  the  unyielding  and  inelastic  character  of  the  cicatrix,  solu- 
tions of  continuity  at  this  site  may  occur  more  readily  than  in  the  soft 
and  elastic  normal  structures.  The  presence  of  dense  and  extensive 
scar-tissue  may  give  rise  to  pain  along  nerve-trunks,  either  from  in- 
volvement of  the  nerve-sheath  in  the  cicatrix,  from  simple  pressure,  or 
from  tension  consequent  upon  shrinking  of  the  cicatrix. 


128  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Certain  degenerative  changes  are  observed  to  occur  in  scar-tissue, 
to  which  the  term  cicatricial  keloid  is  given.  This  condition  is  charac- 
terized by  increased  density,  and  by  deep  reddening  due  to  increased 
vascularity  of  the  scar-tissue,  together  with  growth  into  the  surround- 
ing tissues.  Extirpation,  followed  by  primary  union  and  even  skin- 
grafting  or  transplanting,  does  not  prevent  recurrence.  Electrolysis, 
elastic  pressure,  and  multiple  scarifications  are  recommended,  followed 
after  twenty-four  hours  by  the  application  of  mercurial  ointment  twice 
daily,  the  scarifications  being  repeated  until  the  growth  disappears. 

Degenerative  changes  of  a  malignant  character  are  observed  in  old 
scar-tissue.  This  consideration  does  not  include  recurrences  of  malig- 
nant growths  in  operation-wounds  following  their  extirpation.  True 
cicatricial  carcinomata  are  divided  into  two  groups:  (i)  Those  which 
have  their  origin  in  heretofore  unchanged  and  typical  cicatricial  tissue ;  (2) 
those  which  occur  in  cicatricial  tissue,  the  site  of  previously  existing  but 
benign  ulceration,  such  as  ulcers,  bone-fistulae,  old  urinary  fistulae  about 
,  .  the  penis,  dysenteric  and  tu- 

bercular intestinal  ulceration, 
.  and  parturient  lacerations  of 
the  cervix  uteri.  They  may 
occur,  also,  upon  the  granu- 
lating surface  of  cicatricial  tis- 
sue which  has  never  been  cov- 
ered with  normal  epithelium. 
-.   .  The  disease  may  develop 

■'A      where    tension    is    exercised 
v  upon  a  scar  to  overcome  or 

reduce  deformities  due  to  the 
latter.  It  tends  to  spread 
upon  the  surface,  and,  save 
in  cases  of  extreme  malig- 
nancy, rarely  passes  into  the 
!   depths. 

Tendon. — The  manner 
£  of   healing    in    divided    ten- 

dons will  vary  according  to 
I  the  presence  or  absence  of 
j  blood-clot,    as   well    as    ac- 
cording to  the  maintenance 
NV  ^."-  or  non-maintenance  of  asep- 

tic conditions.  Usually  suf- 
ficient hemorrhage  occurs 
from  the  separated  ends  to 
fill  the  gap  between,with  a 
firm  cylindrical  clot.  A 
growth  of  new  tissue  takes 
;  place  in  the  tendon-sheath 
Fig.  33.-Heaiing  of  tendon.  within    the    first    few    days, 

which  bridges  over  the  space 
between  the  retracted  ends,  and  encloses  the  latter  for  some  distance 
beyond  the  point  of  division  (Fig.   33).     This  new  tissue  consists  of 


THE   REPAIR    OF  SPECIAL    TISSUES.  1 29 

spindle-shaped  cells  whose  long  axis  is  placed  parallel  to  the  tendon. 
It  has  its  origin  in  the  wall  of  the  sheath,  and  not  in  the  divided  edges 
of  the  tendon  itself.  Absorption  of  the  blood-clot  is  induced  by  lateral 
pressure  of  granulations,  which  form  upon  the  borders  of  the  clot  and 
push  their  way  into  its  interior.  From  the  tenth  to  the  fourteenth  day 
a  rich  network  of  vessels  forms  in  the  new  tissue  communicating  with 
the  vessels  in  the  cut  surfaces  of  the  divided  tendon.  An  anastomosing 
network  of  vessels  also  forms  in  the  granulations  which  surround  the 
blood-clot.  With  the  absorption  of  the  clot  the  provisional  new  tissue 
disappears  and  its  fusiform  cells  diminish  in  number,  being  replaced  by 
another  new  tissue  or  intercellular  substance  which  greatly  resembles 
tendon-tissue. 

When  the  tendon-ends  are  widely  separated  the  tendon-cells  take 
but  little  part  in  the  repair,  comparatively  speaking.  When  the  ends 
are  approximated,  as,  for  instance,  in  tendon-suture,  the  new  tissue  still 
more  closely  resembles  tendon-tissue.  Under  these  circumstances  it  is 
believed  that  the  action  of  these  cells  is  more  pronounced  in  the 
regenerative  process. 

The  process  of  repair  in  tendons  therefore  consists  essentially  of 
a  connective-tissue  proliferation  originating  in  the  connective-tissue 
coverings  of  the  tendon,  a  portion  of  which  stretches  from  one 
extremity  to  another  after  the  division  of  the  tendon  proper.  This 
becomes  highly  vascularized,  and  is  then  replaced  by  another  new 
tissue  which  constitutes  the  definite  splice  that  finally  unites  the  di- 
vided ends. 

Extravasation  of  blood  from  the  divided  vessels  between  the  cut 
ends  of  the  tendon  is  not  essential.  When  it  does  not  take  place,  the 
walls  of  the  sheath  come  in  contact  and  a  band  is  formed,  uniting  the 
ends  of  the  tendon.  New  tissue  grows  upon  this  band  and  between  its 
walls,  and  the  same  result  is  attained  as  in  the  case  of  the  interposition 
of  a  blood-clot.  In  fact,  both  excessive  extravasation  of  blood  and 
inflammatory  effusion  from  infection  may  be  highly  disadvantageous  to 
the  reparative  process. 

Muscle. — In  injuries  to  muscle  its  contractility  plays  an  important 
part.  Separation  of  the  fibers  in  a  transverse  direction  results  in  a 
gaping  of  the  wound  in  proportion  to  the  extent  of  the  division. 

Following  a  wound  or  rupture  of  a  muscle  the  blood-vessels  pour 
out  a  mass  of  blood  which  fills  the  gap  between  the  injured  muscular 
fibers.  The  connective  tissue  proliferates  in  the  coagula,  so  that  in  a 
short  time  the  latter  are  absorbed.  With  the  absorption  of  the  blood- 
clot,  which,  up  to  this  time  has  served  as  a  trellis-work  for  the  support 
of  the  new  vessels,  there  remains,  as  a  result  of  the  rapid  connective- 
tissue  proliferation,  a  mass  which  forms  a  swelling  of  exceptionally 
fine  consistence,  the  so-called  muscle-callus,  or  muscular  cicatrix.  Mus- 
cular fibers  in  the  mean  while  are  in  process  of  production,  and  develop 
in  this  newly-formed  tissue  so  as  to  replace  the  latter,  provided  that 
not  more  than  an  inch  of  space  intervenes  between  the  divided  ends 
of  the  muscle.  The  basis  or  groundwork  of  the  regenerative  process 
is  the  fibrillar  in  the  muscle-fiber  (Kolliker).  In  the  case  of  non-striated 
muscular  fiber  the  multiplication  takes  place  by  indirect  or  nuclear 
cell-division,  or  the  process  known  as  karyokinesis.  In  defects  of 
9 


I  ^o 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


unstriped  muscular  fibers  the  regeneration  takes  place  from  the  margins, 

the  center  being  at  first  occupied  by  connective  tissue. 

■ 

In  striated  muscular  fiber  the  first  evidence  of  cell-proliferation  in  the  regenerative  proc- 
ess is  found  in  the  mielei  of  the  muscle-forming  cells,  or  myoblasts,  nearest  the  seat  of  the 
injury  (Tizzoni  |.  With  the  increase  of  these  nuclei  the  new  elements  present  more  or  less 
of  the  figures  characteristic  of  the  karyokinetic  process  (Levern).  The  more  severely  in- 
jured of  tin  musi  ular  fibers  perish  or  undergo  degenerative  changes,  and  are  removed  by 
absorption  within  the  first  few  day.-,,  the  regenerative  process  being  accomplished  in  those 
which  remain  striated  (Klebs)   (Fig.  34.J. 


FlG.  34. — Repair  of  muscle  (x  350) :  a,  nuclei  division  (three  days  after  rupture) ;  b,  mus- 
cle-nuclei transformed  into  protoplasmic  cells,  one  of  them  in  the  stage  of  mitotic  division  ; 
c,  giant  cell  containing  a  necrotic  muscle-fragment  (from  a  muscle-scar  of  twenty-six  days)  ;  d, 
muscle-fibers  ending  in  protoplasma  (from  a  muscle-scar  of  twenty-one  days)  ;  e,  dividing  mus- 
cle-fiber (from  muscle-scar  of  forty-three  days). 


Certain  preliminary  and  temporary  changes  are  observed,  the  principal  feature  of  which 
is  the  development  of  granulation  upon  the  basis  of  cell-division  in  the  perimysium  and  in 
the  endothelia  of  the  small  vessels.  These  granulations  disappear,  and  active  proliferation 
of  muscular  cells  occurs.  These  cells  in  their  turn  disappear  (Nauwerck),  and  elongation 
of  the  remaining  fibers  at  the  seat  of  injury  takes  place.  Later  on,  the  resulting  prolonga- 
tions present  club-shaped  extremities  richly  supplied  with  nuclei.  These  muscular  buds  are 
the  result  of  new-cell  formation  within  the  sarcolemma  ;  they  make  their  way  through  this 
delicate  structure,  appearing  both  at  the  divided  ends  and  upon  the  sides  of  the  fibers.  They 
are  at  first  composed  of  protoplasm  ;  later  they  become  transformed  into  striated  fibers.  As 
the  newly-formed  muscular  fibers  grow  from  opposite  sides  of  the  defect  they  invade  the 
connective-tissue  cicatrix,  become  thicker  and  cylindrical,  and  interlace  (Neumann).  The 
connective-tissue  scar  disappears  more  or  less  completely  according  to  whether  the  defect  to 
be  filled  in  is  a  large  or  a  small  one.  In  small  wounds  the  defect  may  be  filled  entirely  by 
muscular  tissue,  while  in  large  wounds  there  may  be  a  bridging-over  of  the  defect  by  con- 
nective-tissue cicatrix  in  which  there  is  only  a  small  proportion  of  muscular  tissue. 

Nerve. — Following  division  of  a  nerve,  the  first  change  noticed  is 
a  retraction  of  the  sheath.  Myelin  is  then  spread  over  the  divided 
ends,  and  the  latter  become  united  by  a  gray  translucent  tissue.  The 
distance  to  which  the  cut  ends  finally  retract  governs  the  further 
changes  which  occur.  For  several  days  the  distance  between  the  cut 
ends  increases,  owing  to  the  presence  of  some  elastic  fibers  in  the  neuri- 
lemma. With  the  removal  of  a  fourth  of  an  inch  of  a  nerve,  or  the 
separation  of  the  ends  by  this  distance,  regeneration  cannot  take  place 


THE   REPAIR    OF  SPECIAL    TISSUES.  I  3 1 

unless  the  ends  are  brought  together  by  artificial  means.  In  the 
absence  of  approximation  of  the  divided  ends,  the  intervening  space  is 
filled  by  cellular  granulation-tissue  containing  vessels.  This,  in  time, 
forms  a  fibrous  connecting  cord,  devoid  of  nerve-tissue,  between  the 
cut  ends  of  the  nerve.  In  the  meantime  the  ends  of  the  nerves 
undergo  changes,  which  differ,  however,  in  the  two  ends. 

In  the  central  end  the  fibers  are  comparatively  but  slightly  affected 
(Gliick).  The  myelin  is  rapidly  reduced  to  fine  granules,  which,  later 
on,  assume  a  yellowish-brown  color  on  treatment  with  osmic  acid. 
The  nuclei  multiply,  increase  in  size,  and  become  flattened  against  the 
sheath  of  Schwann.  An  infiltration  of  leukocytes  into  the  nerve-sub- 
stance occurs.     The  axis-cylinder  remains  intact. 

The  changes  in  the  peripheral  end  vary  with  the  lapse  of  time  fol- 
lowing the  infliction  of  the  injury.  In  about  fifteen  days  after  the 
injury  segmentation  of  the  myelin  occurs.  The  axis-cylinder  is  almost 
absent  at  this  time.  After  thirty  days  but  a  very  slight  amount  of 
myelin  remains,  and  the  axis-cylinder  is  no  longer  traceable,  while  the 
nuclei  of  the  sheath  are  but  slightly  increased  in  number.  At  the  end 
of  three  months  it  is  no  longer  possible  to  recognize  any  nerve-tubules  ; 
the  nerve-bundles  are  replaced  by  circular  masses  of  tissue  which  have 
the  appearance  of  connective  tissue  with  many  nuclei.  These  proc- 
esses of  degeneration  may  cease  at  a  short  distance  from  the  divided 
end,  or  they  may  involve  the  whole  periphery.  They  commence 
almost  immediately  after  the  injury,  and  continue  until  the  nerve  has 
undergone  complete  atrophy  (Waller). 

The  central  or  upper  end  of  the  nerve  becomes  bulbous,  particularly 
in  stumps  after  amputation.  These  bulbous  growths  upon  the  end  of 
the  nerve-trunk  were  formerly  supposed  to  be  simply  fibrous  tissue; 
but  it  is  now  known  that  they  contain  nerve-elements  as  well,  which 
replace  the  altered  distal  portion  of  the  cut  nerve  (Hayem). 

In  severe  cases  of  contusion  of  nerve  the  changes  are  similar  to 
those  which  occur  in  division.  In  cases  less  severe  there  may  be 
thickening  of  the  neurilemma  at  the  point  of  injur}-,  caused  by  a  col- 
lection of  round  and  spindle-cells.  This  interferes  with  the  processes 
of  regeneration,  and  in  the  course  of  a  few  days  the  degenerative 
changes  of  Waller  set  in,  in  which  both  the  medullary  substance  and 
the  axis-cylinder  are  apparently  implicated  (Tillaux),  and  during  which 
a  temporary,  although  for  the  time  being  complete,  paralysis  occurs. 
Tn  milder  cases  the  axis-cylinder  remains  intact  and  degeneration  does 
not  occur  (Erb). 

This  is  well  exemplified  in  the  so-called  "  Saturday-night  paralysis"  in  which,  in  the 
course  of  a  debauch,  the  patient  falls  asleep  in  a  chair  with  his  arm  hanging  over  its  back  in 
such  a  manner  as  to  cause  prolonged  pressure  upon  the  axillary  nerves.  Here  there  is  a 
slight  hemorrhage  into  the  sheath,  and  a  few  fibers  may  be  separated.  A  large  proportion 
of  the  disturbances,  however,  are  mechanical,  and  simply  involve  displacement  of  the  semi- 
fluid contents  of  the  tubules  (Weir  Mitchell). 

Bone. — The  reparative  process  in  subcutaneous  injuries  to  bone 
consists  in,  first,  resorption  of  effused  fluid  and  destroyed  tissue,  and 
second,  the  formation  of  callus. 

Callus  is  formed  principally  by  the  periosteum  and  medullary  tissue, 
the  former  playing  the  most  important  part  in  its  production.     The 


I32  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

torn  periosteum  becomes  reunited  and  a  ring  of  new-formation  tissue 
develops  at  the  site  of  the  fracture,  constituting  the  so-called  provisional 
callus  of  Dupuytreii.  The  provisional  callus  is  formed  by  the  inner- 
most or  osteogenetic  layer  of  the  periosteum  (Oilier).  During  the  first 
few  days  calcium  salts  are  deposited  between  the  ends  of  the  frag- 
ments. While  the  provisional  callus  is  undergoing  the  process  of  for- 
mation the  medullary  substance  forms  the  definite  callus  of  Cruveilhier. 
While  the  terms  "provisional"  and  "definite"  callus  are  still  retained 
in  descriptions  of  the  reparative  process  in  bone,  yet  they  are  not 
exact,  for  although  the  outer  ring  is  formed  earlier  than  the  connecting 
dowel  from  the  medullary  substance,  both  alike  contribute  to  the 
final  or  definite  repair. 

The  Haversian  canals  likewise  take  part  in  the  reparative  process, 
as  do  also  the  cortical  lamellae,  to  some  extent.  The  ossific  process 
commences  in  the  newly-formed  tissue  between  the  fragments.  The 
latter,  together  with  the  new-formation  tissue  furnished  by  the  perios- 
teum and  medullary  structure,  becomes  solidified  in  a  mass,  with  the 
result  of  complete  formation  of  the  callus.  The  reparative  process  in 
man  occupies  a  length  of  time  varying  from  three  weeks  to  as  many 
months. 

With  the  completion  of  the  reparative  process  there  occurs  a 
gradual  restoration  of  the  callus  to  the  condition  of  true  bone  (Fig.  35). 


Fig.  35. — Union  of  bone  in  rabbit.     Three  weeks. 

This  is  known  as  reformation  of  the  callus  (Lossen),  and  occupies  a 
year  or  more.  It  consists  of  the  production  of  systems  of  regular 
lamellae  and  the  replacing  of  the  dowel  which  divided  the  medullary 
cavity  of  the  bone  into  two  portions,  by  true  medullary  substance.  In 
fractures  involving  the  articular  extremities  of  bones,  the  medullary 
callus  is  finally  converted  into  true  cancellous  tissue.  So  closely  does 
the  reparative  process  follow  the  original  formation  that,  in  fractures  of 
the  neck  of  the  femur  the  reformed  callus  follows  the  lines  best  calcu- 
lated to  bear  the  weight  of  the  body,  as  in  the  normal  state. 

The  histological  process  involved  in  the  formation  of  callus  and  its 
final  regeneration  to  normal  bone,  consisting  as  it  does  of  cell-infiltra- 
tion, new-formation  of  vessels,  and  condensation  of  newly-formed  tissue, 
is  analogous  to  processes  of  repair  in  soft  parts  when  union  by  first 
intention  is  obtained.  The  newly-formed  tissue  is  the  result  of  the 
proliferation  of  existing  osteoblasts  (Fig.  36).  The  traumatic  irritation 
has  reduced  the  bone  to  a  condition  analogous  to  or  identical  with 
young  bone,  as  shown  by  the  fact  that  very  frequently  cartilaginous 


THE   REPAIR    OF  SPECIAL    TISSUES. 


133 


tissue  is  found  in  the  newly-formed  periosteal  callus.  The  manner  in 
which  the  newly-formed  tissues  appropriate  the  salts  necessary  for  their 
proper  construction  is  as  yet  unexplained. 

A  curious  incident  in  connection  with  the  formation  of  callus  is  the 
fact  that,  under  the  influence  of  irritation,  as,  for  instance,  that  which 
occurs  when  extreme  displacement  or  defective  fixation  of  the  frag- 
ments is  present,  the  neighboring  structures  become  the  seat  of  deposits 
of  callus.     Tendinous,  muscular,  and  synovial  callus  develops  in  this 


FIG.  36. — Myelogenous  repair  of  bone  (x  100).  Specimen  from  the  interior  callus  of  a 
fracture  of  the  fibula  fourteen  days  old  :  a,  fat-cells  of  the  medulla  ;  b,  red  marrow ;  c,  dissemi- 
nated osteoblasts  ;  d,  groups  of  osteoblasts  ;  e,  first  formation  of  bone-substance  ;  f,  bone-fibers 
in  stage  of  formation ;  g,  layer  of  osteoblasts  surrounding  newly-formed  bone-fibers  ;  h,  blood- 
vessel. 


manner.  These  callus-masses  take  no  part  either  in  the  temporary  or 
permanent  fixation  of  the  fragments,  and  hence  they  are  known  as 
superfluous  callus. 

In  like  manner  excessive  callus  may  be  formed.  In  this  condition 
an  amount  of  reparative  material,  considerably  in  excess  of  the  require- 
ments of  repair,  is  developed  at  the  site  of  fracture.  Like  superfluous 
callus,  it  results  from  mechanical  irritation  due  to  improper  coaptation 
or  insufficient  fixation  of  the  fragments.  In  the  case  of  transverse 
fracture  the  excessive  callus  is  formed  principally  from  the  osteogenetic 
layer  of  the  periosteum.  Under  these  circumstances  the  circumference 
of  the  bone  may  be  two  or  three  times  greater  than  the  normal.  This 
is  in  part  due  to  the  displaced  fragments,  and  in  part  to  the  demand  for 
a  larger  mass  of  reparative  material  to  bridge  over  the  lateral  surfaces. 
The  latter  is  particularly  the  case  in  fractures  of  the  lower  extremities, 
where  the  callus  assists  in  supporting  the  weight  of  the  body  upon  the 
completion  of  the  process  of  repair.  In  fractures  with  considerable 
longitudinal  separation  of  the  fragments  the  gap  between  the  latter  is 
filled  by  an  excessive  amount  of  callus  which  at  first  develops.  In 
oblique  fractures  with  overriding  fragments  the  excessive  callus  is 
produced  both  by  the  medullary  substance  and  by  the  periosteum. 

Cartilage. — Owing  to  its  non-vascular  structure,  as  well  as  to 
absence  of  channels  for  plasma-circulation  and  the  consequent  limited 
nutritive  supply,  the  reparative  capacity  of  cartilage  is  very  low.  In 
Redfern's  studies  of  experimental  wounds  in  articular  cartilage  the 
wound   was   found  to   be   unchanged   after    twenty-nine   days   in   one 


134 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


instance.  In  cases  of  incised  wounds  of  cartilage  experimentally  made 
upon  dogs  by  Geiss,  when  but  slight  traumatism  was  inflicted  and 
aseptic  conditions  were  maintained,  it  was  found  that  the  wounds 
refused  to  heal ;  while,  on  the  other  hand,  wounds  made  in  the  pres- 
ence of  micro-organisms  underwent  rapid  repair. 

Following  fracture  of  cartilage  covered  by  perichondrium,  regressive 
changes  take  place  at  the  seat  of  injury,  the  broken  ends  undergoing 
fatty  degeneration.  The  reparative  process  is  initiated  at  a  short  dis- 
tance from   the   line   of   separation   (Fig.    37).      Vascularization  takes 

h 


d!  d* 

FlG.  37. — Repair  of  cartilage  covered  by  perichondrium  (x  ioo)  (after  Ziegler).  Specimen 
after  a  fracture  of  five  days  :  a,  cellular  plastic  tissue  ;  b,  cartilage-tissue  ;  c,  proliferating  cells 
from  the  perichondrium  ;  d,  cartilage-cells;  d' ,  dv ',  nuclear  division  of  cartilage-cells  ;  e,  matrix 
of  the  plastic  tissue ;  f,  matrix  of  cartilage ;  g,  capsule  of  cartilage-cells  ;  h,  proliferating  endo- 
thelia  of  a  blood-vessel. 

place  from  the  marginal  vessels  of  the  perichondrium,  and  a  connective- 
tissue  proliferation  fills  the  space.  The  repair  takes  place  almost  ex- 
clusively through  the  perichondrium  (Gussenbauer). 

The  tissue-proliferation  resulting  from  the  division  and  development  of  the  cells  of  this 
structure  is  followed  by  the  formation  of  a  fibrous  cartilaginous  tissue  which  undergoes 
changes  toward  ossification.  It  is  highly  probable  that  the  cartilage-cells  take  but  little,  if 
any,  part  in  the  reparative  process,  although  Reitz  thought  he  had  traced  the  formation  of 
connective  tissue  from  cartilage-cells,  the  latter  being  first  transformed  into  spindle-cells,  and 
then  into  connective  tissue.  His  experiments  were  made  upon  the  cartilage  of  the  trachea 
of  the  rabbit,  while  Redfern's  were  made  upon  articular  cartilage  ;  it  was  to  this  that  Reitz 
attributed  the  discrepancy  in  the  results.  Doerner's  studies  upon  the  manner  of  repair  of 
incised  wounds,  as  well  as  more  complicated  injuries  of  cartilage,  confirmed  the  observations 
of  Redfern  and  Gussenbauer  that  the  perichondrium  is  invariably  found  to  take  the  most 
active  part  in  the  process  of  healing. 

In  case  of  injury  to,  or  loss  of  substance  of,  the  cartilage  of  joints, 
which  is  not  furnished  with  perichondrium,  a  fibrous  connective-tissue 
cicatrix  develops,  which  in  the  course  of  time  is  changed  into  hyaline 
cartilage-tissue  (Tizzoni).  On  the  other  hand,  it  is  believed  that  de- 
fects of  joint-cartilage  arising  from  a  trauma  undergo  only  partial  repair, 
the  cartilage-cells  possessing  but  low  vegetative  power.  Whatever 
tissue-proliferation   occurs  is  transformed  into  connective  tissue. 

When  portions  of  joint-cartilage  have  been  completely  separated 
they  do  not  become  reattached  to  the  joint-surfaces  either  at  the 
original  point  of  attachment  or  elsewhere.  They  either  become  free 
floating  bodies  in  the  joint,  or  are  encapsulated  or  attached  by  a  new 
connective-tissue  covering  which  springs  from  the  inner  surface  of  the 
capsule. 


THE   REPAIR    OF  SPECIAL    TISSUES.  1 35 

Arteries. — The  blood-vessels  are  composed  of  unstriped  muscular 
fibers,  elastic  tissue,  connective  tissue,  and  endothelium.  It  has  been 
customary  to  distinguish  three  coats,  and  to  designate  these,  according 
to  their  location,  as  the  internal,  or  intima ;  the  middle,  or  media ;  and 
the  external,  or  adventitia. 

The  intima  is  a  delicate,  elastic,  and  transparent  membrane,  com- 
posed, in  the  case  of  the  larger  arteries,  of  a  layer  of  flat  endothelial 
cells,  a  delicate  layer  of  longitudinally-arranged  connective  tissue,  and 
elastic  tissue.  The  endothelial  cells  are  irregularly  polygonal  in  shape 
and  have  an  oval  nucleus.  Sometimes  the  outer  surface  of  the  base- 
ment-membrane of  the  intima  is  covered  by  a  layer  of  polyhedral  cells, 
the  so-called  epithelioid  cells  (Czerny).  In  larger  arteries  there  is  an 
additional  connective-tissue  membrane,  which  in  the  adult  is  distinctly 
fibrillated  (the  striated  internal  coat  of  Kolliker). 

The  media  is  composed  of  unstriped  muscular  fibers,  elastic  and 
connective  tissues.  In  small  and  medium-sized  vessels  the  propor- 
tionate amount  of  muscular  tissue  is  greatest,  while  in  larger  arterial 
trunks  the  elastic  tissue  preponderates.  The  muscular  fibers  are  of 
the  smooth  nucleated  variety,  and  are  arranged  in  a  circular  manner. 
In  the  larger  vessels  there  is  a  longitudinal  muscular  layer  as  well 
(Bardeleben).  While  the  circular  direction  of  the  muscular  fibers  is 
maintained  in  a  general  way,  in  addition  to  the  longitudinal  layer  just 
mentioned,  there  are  some  which  have  an  oblique  direction.  These 
prevent  complete  separation  of  the  middle  coat  when  a  round  ligature 
is  tightly  applied  to  the  vessel.  The  elastic  tissue  of  the  middle  coat 
is  disposed  in  three  layers.  One  is  imposed  between  this  coat  and  the 
intima,  another  is  connected  with  the  external  coat,  while  a  third  is 
arranged  so  as  to  fill  the  interspaces  between  the  muscular  layers 
which  lie  between  the  two  elastic  layers  already  described.  The  elas- 
tic fibers  correspond  in  direction  to  the  muscular  fibers.  It  was  for- 
merly the  general  belief  that  the  middle  coat  of  an  artery  was  not 
regenerated  or  reproduced  when  injured  or  destroyed,  but  that  only  a 
reparative  process  occurred,  which  took  place  by  the  formation  of  a 
simple  connective-tissue  cicatrix.  This  view  is  opposed  by  Warren 
{vide  infra). 

The  adventitia,  or  external  coat,  is  composed  of  closely-woven 
bundles  of  connective  tissue,  together  with  more  or  less  elastic  tissue 
arranged  in  layers.  The  principal  function  of  the  external  coat  is  to 
serve  as  a  support  for  the  nutrient  vessels  of  the  arterial  wall  itself 
(the  vasa  vasorum),  which  rarely  spring  from  the  vessel  that  they 
supply,  but  are  derived  from  neighboring  arterioles  (Flint). 

The  processes  of  repair  in  blood-vessels  have  been  studied  more 
or  less  completely  by  almost  even*  experimental  pathologist  since  the 
days  of  John  Hunter,  who  first  enunciated  the  theory  of  the  organiza- 
tion of  the  thrombus  as  a  necessary  part  of  the  reparative  process. 
The  history  of  the  study  of  the  behavior  of  vessels  after  injury  is  the 
history  of  the  evolution  of  the  theory  of  cell-action  and  the  part  which 
it  plays  in  the  building  up  of  new-formation  tissue  in  all  the  structures 
of  the  body,  since,  in  the  injured  vessel,  can  be  studied  the  action  of 
the  colorless  blood-corpuscles,  the  wandering  cells,  the  fixed  connec- 
tive-tissue corpuscles,  and  the  endothelium. 


I36  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Contusions  produce  more  or  less  tearing  of  the  smaller  vessels, 
both  arteries  and  veins,  in  the  subcutaneous  connective  tissue.  As  the 
blood  escapes  into  the  meshes  of  the  latter,  it  coagulates  and  forms 
what  is  known   as  a  hematoma. 

Contusion  of  an  artery  is  sometimes  occasioned  by  a  bullet  or  other 
missile  striking  it  and  glancing  off.  The  injury  to  the  tissue  of  the 
vessel  may  be  so  great  as  to  cause  final  rupture  of  the  vessel.  In 
other  cases  the  supposed  contusion  proves  to  be  really  a  partial  rupt- 
ure of  the  artery,  a  portion  of  the  intima  giving  way  and  curling  up 
so  as  to  cause  occlusion  more  or  less  permanent  at  this  point. 

When  the  trunk  of  a  large  artery  is  wounded,  in  addition  to  the 
blood  which  escapes  from  the  interior  of  the  vessel,  there  is  a  hemor- 
rhage from  the  wounded  nutrient  vessels  which  are  severed  in  the 
adventitia.  The  blood  from  this  wound  in  the  vessel-wall  coagulates, 
arresting  the  bleeding.  The  coagulum  thus  formed  extends  in  the 
interior  for  varying  distances.  Under  these  circumstances,  unless 
there  is  an  external  wound,  a  large  and  tense  hematoma  is  found  out- 
side the  vessel.  This  hematoma,  together  with  the  coagulum  in  the 
wound  in  the  vessel-wall,  as  well  as  that  portion  of  it  which  extends 
within  the  vessel,  usually  forms  one  solid  mass  of  blood-clot.  The 
process  of  repair  now  begins.  Absorption  of  the  blood-clot  occurs, 
and  as  this  proceeds  that  portion  of  the  mass  which  sealed  the  wound 
in  the  vessel-wall  is  replaced  by  glandular  tissue.  Finally  a  cicatrix 
of  connective-tissue  origin  replaces  the  normal  structure.  This  forms 
a  weak  point  which,  when  subjected  to  arterial  pressure,  is  gradually 
forced  in  an  outward  direction  until  an  aneurysmal  sac  is  formed. 

When  an  artery  is  completely  severed,  subjected  to  torsion,  or 
ligated,  permanent  obliteration  of  the  vessel  usually  follows,  either 
through  natural  or  artificial  means.  This  takes  place  by  the  forma- 
tion of  an  intravascular  cicatrix.  The  basis  of  the  reparative  process 
is  a  thrombus  within  the  vessel  itself.  This,  however,  only  plays  a 
passive  role,  the  repair  proper  being  invariably  effected  by  cell-prolif- 
eration from  the  vessel-wall.  This  is  in  opposition  to  the  view  for- 
merly held,  that  the  thrombus  became  vascular  either  from  the 
nutrient  vessels  of  the  adventitia  or  from  the  lumen  of  the  vessel 
itself,  and  that  the  intravascular  cicatrix  was  built  up  from  the  histo- 
logical elements  of  the  thrombus.  One  of  the  most  potent  arguments 
against  this  doctrine  is  the  fact  that  coagulation  of  the  blood  occasion- 
ally fails  to  take  place,  and  that  primary  union  of  the  inner  wall  occurs 
without  the  formation  of  a  thrombus.  Further,  there  is  no  more 
reason  to  expect  that  the  morphological  elements  of  a  thrombus  will 
initiate  and  carry  on  tissue-proliferation  than  that  they  will  produce 
blood-extravasations  elsewhere.  On  the  contrary,  it  is  a  generally 
recognized  fact  that  these  latter  invariably  undergo  retrograde  meta- 
morphosis. 

When  an  artery  is  tightly  constricted  or  subjected  to  torsion,  the  cur- 
rent of  blood  is  permanently  arrested.  The  innermost  coat,  and  to  some 
extent  the  middle  coat,  gives  way.  The  adventitia,  or  outermost  coat, 
remains  intact,  and,  in  case  of  ligature,  is  constricted  into  a  narrow 
circle.  The  internal  and  middle  coats,  mainly  from  their  elasticity, 
retract    and    curve    upon   themselves,  as    division    takes   place.     Two 


THE   REPAIR    OF  SPECIAL    TISSUES. 


l37 


thrombi  form,  one  above  and  the  other  below  the  point  of  constric- 
tion.    The  former  is  usually  the  larger  of  the  two. 

It  was  formerly  supposed  that  the  mere  arrest  of  the  blood  at  the 
point  of  obstruction  was  sufficient  to  cause  its  coagulation.  Alex. 
Schmidt  has  shown,  however,  that  a  third  body,  having  its  origin  in 
the  so-called  blood-plaques,  the  disintegration  of  which  gives  rise  to  a 
ferment,  is  necessary.  The  coats  of  the  artery  being  ruptured,  the  dis- 
integration of  the  cells  containing  the  fibrin-ferment  is  initiated,  and 
fibrin  is  deposited  upon  the  recurved  tunics.  In  the  event  of  failure  of 
coagulation,  the  two  opposing  surfaces  may  cohere  by  multiplication 
of  the  endothelial  cells  (Riedel).  When  the  clot  is  formed,  which  may 
occur  in  an  hour  and  is  rarely  delayed  beyond  six  hours,  it  not  infre- 
quently passes  into  the  collateral  branches  (Ballance  and  Edmunds). 
Coagulation  takes  place  likewise  when  the  tunics  are  injured  sufficiently 
to  prevent  the  blood-current  from  continuing  its  course  (Michael 
Foster).  A  profound  alteration  of  the  nutrition  now  takes  place.  The 
vasa  vasorum  become  blocked  and  a  plastic  effusion  ensues.  The  loop 
of  the  ligature  is  buried  in  the  effusion.  The  opposed  endothelial  sur- 
faces proliferate  and  adhesions  form  between  them.  This  effusion 
occurs  more  rapidly  when  the  coats  are  ruptured.  In  the  course  of 
the  first  two  days  granulation-tissue  forms  about  the  point  of  ligature, 
as  well  as  for  some  distance  above  and  below  the  point  of  the  latter. 
The  inflammatory  product  varies  in  amount,  being  governed  by  the 
grade  of  the  traumatism  inflicted,  as  well  as  by  the  presence  or  absence 
of  sepsis.  As  a  result  of  cell-proliferation  a  callus  is  formed,  which 
protects  the  vessel  from  the  dangers  of  hemorrhage.  An  apparent 
ampullation  of  the  vessel  occurs  immediately  above  the  clot  (Bryant). 
This  enlargement,  however,  is  more  apparent  than  real,  and,  in  reality, 
depends  upon  a  contraction  of  the  vessel  above  the  clot  (Warren). 

The  function  of  the  clot  is  threefold :  First,  it  acts  as  a  cushion 
against  which  the  impulse  of  the  blood  is  received,  and  in  this  manner 
prevents  disturbance  of  the  plastic  process  ;  second,  it  forms  a  trellis- 
work  support  to  invasion  and  proliferation  of  cells  as  they  advance 
from  side  to  side  of  the  internal  coat  of  the  arterial  tube ;  third,  it 
furnishes  nutriment  to  these  cells. 

If  repair  progresses  favorably  the  granulation-tissue  penetrates 
deeply  into  the  thrombi,  and  also  exercises  a  solvent  action  upon  the 
bundles  of  fibers  surrounded  by  the  ligature.  The  process  of  healing 
from  this  point  resembles  the  repair  of  fractures.  The  new-formation 
material  within  the  vessel  is  comparable  to  the  internal,  and  that  out- 
side the  vessel  to  the  external,  callus  of  a  fracture  (Warren)  (Fig.  38). 
These  structures  are  of  a  provisional  character.  Upon  their  disap- 
pearance it  is  found  that  a  growth  has  taken  place  in  the  intima 
which  forms  a  permanent  cicatrix.  According  to  Warren,  this  cicatrix 
represents  a  reproduction  of  the  three  walls  of  the  vessel.  Its  innermost 
layer  is  composed  of  endothelium,  its  outermost  layer  is  a  connective- 
tissue  formation  from  the  adventitia,  and  between  these  there  is  found  a 
layer  of  muscular  cells  developed  from  the  middle  coat  of  the  vessel. 
With  the  absorption  of  the  provisional  tissue  and  the  complete  formation 
of  the  definite  cicatrix,  the  latter  acts  as  a  connecting  cord  between  the 
two  ends  of  the  vessels  (Fig.  39).     A  small  central  vessel  penetrates 


138 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


' 


the  cicatrix.  This  replaces  the  network  of  vessels  which  supplied  the 
provisional  tissue  and  disappeared  with  the  latter.  It  passes  from  the 
lumen  and  anastomoses  with  the  system  of  capillaries  which  surround 
the  stump  of  the  obliterated  artery. 

A  ligature  applied  to  a  blood-vessel  is  always  treated  as  a  foreign 

body  by  the  tissues,  and 
an  attempt  is  at  once 
made  by  the  cells  to  ab- 
sorb it.  The  success  of 
this  attempt  will  depend 
upon  the  nature  of  the 
ligature-material.  Gold- 
or  platinum-wire  liga- 
ture remains  perma- 
nently in  an  unchanged 
condition.  Lead,  silver, 
iron,  and  other  metals 
disappear  by  absorption 
sooner  or  later.  All  ani- 
mal and  vegetable  liga- 
tures are  disintegrated 
and  absorbed  in  time, 
varying  with  the  char- 
acter of  the  ligature-ma- 
terial and  the  method  of 
its  preparation.  If  there 
is  any  delay  in  the  ab- 
sorption, encapsulation 
occurs  from  the  forma- 
tion of  connective  tissue. 
The  absorption,  however, 
is  not  arrested  on  this  ac- 
count, but  goes  on,  al- 
though slowly,  to  com- 
pletion. As  absorption 
takes  place  the  ligature- 
material  is  replaced  by 
new  connective  tissue. 
In  the  case  of  animal 
ligatures  the  softening 
and  absorption  of  the 
ligature  occur  earlier  if 
suppuration  takes  place. 
With  the  arrest  of  the 
blood-current  at  the  seat 
of  ligature  the  flow  of 
pressure  toward  the  lat- 
to   the   point   of  obstruc- 


FlG.  38. — Carotid  artery 
of  horse  two  weeks  after 
ligature.  Callus-formation 
(Warren). 


Fig.  39. — Carotid  artery 
of  horse  three  months  after 
ligature.  Partial  absorp- 
tion of  callus. 


blood   is   at   once    directed   with    increased 

eral  branches  which   are  given   off  nearest 

tion.       These   lateral    branches  communicate   with    arteries    from   the 

arterial   trunk    beyond  the   obstruction.       In   this    manner  the   blood 

finally  reaches  its  original  destination.     This  anastomotic  or  collateral 


THE   REPAIR    OF  SPECIAL    TISSUES.  1 39 

circulation  is  usually  restored  at  once,  and  forms  for  itself  more  or 
less  wide  channels  for  carrying  on  the  circulation.  The  combined 
area  of  these  collateral  branches  equals  that  of  the  trunk  which 
has  been  obstructed.  In  exceptional  instances  in  which  diseased  con- 
ditions of  the  arteries  exist,  or  where  infiltration  of  the  surrounding 
tissues  prevents  a  prompt  enlargement  of  the  anastomosing  branches, 
the  blood-supply  to  the  periphery  is  retarded  or  entirely  prevented 
(see  Gangrene). 

Glands. — The  repair  which  takes  place  in  glandular  structures  is 
accomplished  by  a  regeneration  of  the  gland-substance.  In  the  case 
of  partial  excision  of  a  gland,  as,  for  instance,  in  the  testicle,  there  is 
an  increase  of  the  essential  anatomical  structure,  the  tubuli  seminiferi, 
during  the  healing  process  (Griffin).  In  experiments  upon  dogs,  Tizzoni 
observed  production  of  new  hepatic  tissue  in  wounds  of  the  liver  as 
healing  took  place.  In  the  case  of  the  spleen,  even  in  complete  extir- 
pation of  this  organ,  there  is  a  very  effective  effort  made  toward  the 
restoration  of  function  by  the  production  of  new  gland-tissue  from  the 
blood-vessels  of  the  neighboring  peritoneum.  Tissue-proliferation  takes 
place  in  the  adjacent  vessels,  the  product  of  which  corresponds  to  nor- 
mal splenic  tissue,  both  in  its  anatomical  characteristics  and  its  physio- 
logical properties.  The  newly-formed  gland-tissue  occurs  as  isolated 
nodules  which  develop  around  new  offshoots  from  the  vessels  of  the 
peritoneum  about  the  site  of  the  hilus,  which,  appearing  in  the  begin- 
ning as  new  connective  tissue,  is  finally  supplied  with  follicles,  pulp, 
and  a  proper  arrangement  of  blood-vessels.  That  these  possess  the 
function  of  the  original  spleen  is  shown  by  the  fact  that  the  blood- 
corpuscles,  which  had  been  diminished  following  the  extirpation  of  the 
organ,  increase  in  number  as  the  new  splenic  tissue  is  produced 
(Tizzoni  and  Fileti).  Nor  does  it  seem  essential  that  the  entire  spleen 
should  be  removed  in  order  that  production  of  new  spleen-tissue  should 
occur  from  the  vessels  of  the  peritoneum.  The  excision  of  a  portion 
of  the  organ  is  followed  by  the  formation  of  new  spleen-tissue  upon 
the  omentum  in  the  neighborhood,  entirely  independently  of  tissue- 
proliferation  in  the  wound  in  the  spleen  itself. 

In  a  similar  manner,  it  is  claimed,  new  lymphatic  tissue  is  rapidly 
produced  after  partial  or  complete  removal  of  a  lymphatic  gland,  the 
vessels  of  the  adjoining  adipose  tissue  serving  the  same  purpose  as 
those  of  the  peritoneum  in  the  production  of  splenic  tissue  (Baier  and 
Bacialli).  It  is  more  than  probable,  however,  that  the  new  gland-tissue 
is  the  product  of  tissue-proliferation  from  the  divided  ends  of  lymphatic 
vessels. 


CHAPTER    VI. 

CONSTITUTIONAL  REACTIONS  TO  WOUNDS  AND  THEIR 

INFECTIONS. 

ASEPTIC  WOUND  FEVER;  SAPREMIA;  SEPTIC  INTOXICATION;   SEP- 
TICEMIA;  PYEMIA;  SEPTICOPYEMIA. 

When  local  injuries  have  been  inflicted  upon  the  animal  body,  a 
constitutional  reaction  is  prone  to  follow — a  reaction  in  which  are  asso- 
ciated elevation  of  the  body-temperature,  and  cardiovascular,  respiratory, 
and  nervous  phenomena  which  we  designate  under  the  clinical  term 
fever.  It  is  not  within  our  province  to  discuss  the  essential  nature  of 
the  fever,  but  only  to  consider  its  relationship  to  surgical  conditions. 
Neither  is  it  our  purpose  to  dwell  upon  that  hyperthermia  which 
occurs  after  the  passing  of  the  catheter  or  sound,  when  unassociated 
with  infection  or  renal  lesions,  and  which,  as  it  is  a  simple  vasomotor 
disturbance,  is  better  referred  to  another  classification  than  that  of 
fever   (Kraus). 

The  common  pathological  element  in  all  forms  of  fever  is  intoxica- 
tion. The  poisons  which  bring  about  the  fever  are  of  different  origins, 
and  gain  entrance  to  the  circulation  in  a  variety  of  ways. 

AUTO-INTOXICATION. 

Auto-intoxication  is  an  expression  of  recent  origin,  used  to  desig- 
nate that  form  of  self-poisoning  in  which  neither  wound  nor  gross 
pathological  lesion  exists,  but  in  which  poisons  elaborated  within  the 
body  are  not  excreted  with  proper  activity,  so  that  the  system  at  large 
is  injured.  While  auto-intoxication  is,  therefore,  not  dependent  upon 
any  form  of  wound-complication,  a  slight  knowledge  of  it  is  neverthe- 
less so  important  for  our  study  of  wound-infection  that  we  will  very 
briefly  refer  to  it. 

A  simple  and  familiar  kind  of  auto-intoxication  is  that  in  which  the 
bowels  do  not  empty  themselves  freely  enough,  so  that  the  products 
of  putrefaction  from  the  intestine  and  excrementitious  matters  from  the 
liver  and  the  intestinal  mucosa  are  not  cast  out  promptly,  but  remain 
long  enough  in  the  body  to  be  partly  resorbed.  The  skin,  the  lungs, 
the  kidneys,  the  liver,  and  the  intestines  are  the  most  important  ex- 
cretory organs.  Interference  with  the  activity  of  any  one  of  them 
may  result  in  the  retention  of  poisons  which  cause  a  great  variety  of 
functional  disturbances  depending  for  their  peculiarities  upon  the 
properties  of  the  retained  chemical  bodies.  The  greatest  activity  is 
now  being  manifested  by  scientific  men  in  this  complex  and  difficult 
field,  and  many  chemical    compounds   have  been  isolated  from  the 

140 


A  UTO-INTOXICA  TION. 


I4I 


excreta,  their  chemical  formulae  ascertained,  and  their  physiological 
properties  determined. 

Auto-intoxication  is  of  especial  importance  to  the  surgeon,  because 
the  traumatic  infectious  organisms  find  the  tissues  of  an  animal  de- 
pressed by  the  resorption  of  excrementitious  principles  much  more 
vulnerable  than  those  of  a  normal  individual.  All  experienced  sur- 
geons realize  the  very  great  importance  of  having  the  bowels  in  a  good 
state  of  activity  at  the  time  of  performing  operations.  Not  only  this, 
but  many  insist  that  the  intestines  be  as  nearly  empty  as  possible,  and 
that  the  so-called  intestinal  antiseptics  be  given  beforehand,  since  the 
loss  of  even  a  moderate  amount  of  blood,  and  especially  the  frequent 
inability  to  retain  water  in  the  stomach,  make  resorption  of  fluids  from 
the  intestines,  which  always  contain  more  or  less  noxious  matter  in 
solution,  especially  likely  to  occur.  This  danger  may  be  partly  averted 
by  injecting  into  the  rectum  4  to  8  ounces  of  sterilized  water  every 
three  to  six  hours  after  the  operation,  until  abundant  urinary  secretion 
tells  us  the  blood-volume  is  made  up  and  that  excretion,  by  that 
important  avenue  at  least,  is  going  on  well.  For  the  same  reason 
patients  should#  not,  as  a  rule,  be  denied  abundance  of  drinking  water, 
after  post-operative  vomiting  has  ceased,  unless  some  especial  indica- 
tion exist  for  denying   it. 

To  prevent  the  ill  effects  of  excessive  auto-intoxication,  one  must  be 
especially  upon  his  guard  in  certain  progressive  organic  diseases  in 
which  surgical   operations  are  often  required. 

For  example,  in  diabetes  we  are  cautioned  to  defer  amputation  for  gangrene,  if  possible, 
until  the  glycosuria  is  reduced  to  as  low  a  point  as  possible  ;  and  in  the  various  renal  mala- 
dies operations  of  election  are  deferred  until  the  function  of  urinary  excretion  is  performed 
with  maximum  activity.  It  is  important  to  interrogate  the  condition  of  the  kidneys  and  of 
the  heart,  upon  which  renal  activity  so  much  depends,  before  undertaking  surgical  pro- 
cedures which,  by  throwing  additional  burdens  on  the  eliminating  organs,  may  cause  an 
auto-intoxication  which,  if  not  dangerous  in  itself,  may  become  so  by  favoring  local  or  general 
infection. 

The  diagnosis  of  auto-intoxications  must  be  made,  partly  by  a 
reference  to  the  positive  symptoms  associated  with  the  partial  func- 
tional failure  of  the  different  organs,  partly  by  the  exclusion  of  various 
forms  of  intoxication  of  a  more  strictly  surgical  character  yet  to  be 
discussed.  The  commonly  prompt  occurrence  of  furred  tongue,  a 
bitter  taste  in  the  mouth,  headache,  anorexia,  and  malaise  with  a  slight 
rise  of  fever  after  failure  of  defecation  for  twenty-four  or  forty-eight 
hours,  suggests  the  need  of  laxatives.  Persistent  headache,  a  tense 
small  radial,  a  hypertrophied  left  ventricle,  mental  wandering  or  de- 
lirium, twitching  of  the  limbs  or  of  muscle-groups  together  with  more 
direct  evidences,  call  attention  to  renal  insufficiency.  For  the  refine- 
ments of  diagnosis  in  this  department  the  reader  must  seek  the  works 
on  internal  medicine. 

The  treatment  of  auto-intoxications  by  medieval  and  even  com- 
paratively modern  practitioners  was  largely  by  phlebotomy.  This  was 
not  wholly  without  propriety,  since  the  removal  of  a  comparatively 
small  quantity  of  blood  and  its  substitution  by  water  insure  the  im- 
mediate removal  from  the  body  of  a  quantity  of  concentrated  poison- 
ous matter  which  it  would  require  a  vastly  larger  amount  of  urine  and 


142  INTERNATIONAL    TEXT- BOOK  OE  SURGERY. 

very  much  more  time  to  carry  away.  Practically,  however,  we  now 
reach  the  same  result  by  using  laxatives,  diuretics,  and  sudorific 
remedies. 

ASEPTIC  WOUND  FEVER. 

Aseptic  wound  fever  is  an  expression  used  by  Volkmann  to  in- 
dicate the  systemic  reaction  taking  place  in  the  bodies  of  those  in 
whom  wounds  are  healing  without  the  interference  of  infection — as,  for 
example,  in  simple  fractures. 

( iussenbau'er  has  called  attention  to  the  illogical  character  of  the  expression,  since  a  term 
indicating  the  mere  absence  of  a  pathological  characteristic  should  not  serve  to  denote  a 
morbid  entity.  Other  names  are  sometimes  used.  Ferment  fever  was  an  expression  sug- 
gested by  Bergmann  under  the  misconception  that  the  fibrin-ferment  of  effused  or  disinte- 
grated blood  was  the  active  agent  in  producing  the  fever.  Resorption  fever,  after-fever 
(Billroth),  ami  simple  traumatic  fever  are  other  more  or  less  convenient  or  suggestive  addi- 
tions to  the  terminology. 

Etiology. — The  cause  of  this  form  of  transitory  fever  coming  on 
a  few  hours  after  injury  was  sought  by  many  earlier  observers  in  the 
liberation  and  resorption  of  fibrin-ferment  from  the  blood.  It  was  ob- 
served that  after  transfusions  of  blood,  in  which  many,  millions  of  red 
corpuscles  are  destroyed,  and  when  tissues  were  suddenly  killed  by 
traumatism,  a  rise  in  temperature  occurred  even  in  the  absence  of  infec- 
tion. The  same  thing  was  seen  to  occur  even  when  inert  substances 
like  charcoal  were  introduced  into  the  veins.  It  was  supposed  that 
these  substances  brought  about  destruction  of  some  blood-corpuscles, 
and  that  thus  the  fibrin-ferment  was  set  free. 

Schnitzler  and  Ewald,  working  in  Albert's  clinic  in  Vienna,  have  recently  studied  anew 
the  fever-producing  chemical  bodies  indisputably  set  free  in  subcutaneous  hemorrhages. 
While  asserting  that  the  older  notions  of  the  chemistry  of  fibrin-ferment  must  be  so  modified 
as  to  agree  with  the  results  of  modern  research,  and  that  the  fibrin-ferment  cannot  any  longer 
be  regarded  as  the  active  fever-producing  body  in  effused  blood,  they  endeavored  to  isolate 
from  such  blood  those  chemical  bodies  which  produce  the  symptoms  of  aseptic  wound  fever. 
They  claim  to  have  found  two  series  of  compounds  exactly  meeting  these  requirements — the 
nucleins  and  the  albumoses.  Both  these  substances  are  found  in  effused  aseptic  blood  ;  both 
substances  when  injected  into  the  bodies  of  healthy  animals  bring  about  a  febrile  reaction. 
Besides  this,  nucleins  are  known  to  be  present  in  some  of  the  supposedly  inert  substances 
(e.  o-. ,  wheat  flour)  formerly  injected  experimentally  into  the  blood  of  animals  to  produce 
this  febrile  disturbance. 

The  exact  conditions  under  which  this  kind  of  fever  is  produced 
are  not  as  yet  determined.  Certainly  there  are  many  cases  of  extensive 
extravasation  of  blood  that  are  followed  by  but  slight  reaction.  The 
converse  of  the  proposition  is  equally  true,  that  often  very  small  in- 
juries are  followed  by  great  reaction.  Doubtless  the  activity  of  the 
emunctory  organs  at  the  time  of  injury  constitutes  an  important  factor. 
Some  maintain  that  the  pressure  to  which  the  effused  blood  is  sub- 
jected is  a  favoring  moment.  The  resorptive  powers  of  the  tissues 
that  are  in  contact  with  the  blood  are  significant. 

After  operations,  this  form  of  fever  is  most  likely  to  follow  when 
hemostasis  has  not  been  perfect,  when  drainage  has  been  omitted,  or 
when  manipulation  of  a  great  amount  of  tissue  has  been  prolonged 
and  severe.  Tillmanns  considers  the  use  of  antiseptics  in  the  wound 
an  important  causative  element,  since  these  chemicals  destroy  quantities 
of  tissue-cells  and  predispose  to  post-operative  oozing  of  blood. 

The  symptoms  of  primary  or  aseptic  wound  fever  are  simple  and 


SAPREMIA.  143 

not  numerous.  A  few  hours  after  a  trauma,  operative  or  accidental, 
the  temperature  rises  to  ioo°,  1010,  or  even  1020  F.,  rarely  higher. 
The  rise  of  temperature  being  gradual,  and  the  degree  attained  not 
high,  a  rigor  does  not,  as  a  rule,  occur.  The  pulse  increases  in  fre- 
quency in  correspondence  with  the  fever.  The  face  may  be  slightly 
flushed  and  the  tongue  dry.  The  eyes  are  bright,  and  the  patient 
makes  but  little  complaint  except  to  beg  for  water.  These  symptoms 
are  of  very  transitory  character.  In  a  few  hours,  or  within  two  days, 
the  reaction  is  over,  and  henceforth  the  temperature  remains  normal 
throughout  the  course  of  healing. 

The  diagnosis,  in  the  presence  of  these  somewhat  vague  and  un- 
characteristic symptoms,  must  rest  chiefly  on  a  careful  exclusion  of 
other  fever-producing  conditions  in  the  wound,  and  particularly  upon 
the  exclusion  of  inflammations  in  other  parts  of  the  body  (pneumonia, 
bronchitis,  nephritis).  Since  the  prompt  termination  of  the  febrile 
movement  is  a  most  typical  element  in  the  symptomatology,  the  clini- 
cal observer  anxiously  watches  for  the  defervescence  to  enable  him  to 
exclude  the  more  dreaded  wound-complications.  In  practice,  we  give 
but  little  anxiety  to  a  moderate  rise  of  temperature  during  the  first 
twenty-four  hours  after  traumatism. 

The  treatment  of  this  form  of  wound-reaction  is,  in  operative  sur- 
gery chiefly,  and  most  properly,  prophylactic.  The  proper  preparation 
of  the  patient,  diminution  of  traumatism,  abstinence  from  the  use  of 
chemical  antiseptics,  and  curtailment  of  exposure  to  air  are  important 
points.  Laxatives  after  operations  are  often  used.  Enemata  of  warm 
water,  to  be  retained  and  resorbed,  aid  in  elimination  of  the  poisons. 
In  laparotomies  for  non-infectious  lesions  it  is  common  and  good  prac- 
tice to  leave  in  the  abdomen  a  quantity  of  sterilized  water,  the  absorp- 
tion of  which  increases  diuresis  and  diaphoresis. 

SAPREMIA. 

The  fevers  thus  far  discussed  have  been  regarded  as  due  to  the 
resorption  of  toxins  not  elaborated  by  the  action  of  bacteria,  if  we 
except  the  case  of  auto-infection  from  putrefaction.  We  have  now 
to  consider  the  systemic  consequences  of  the  invasion  of  wounds  and 
wound-products  by  micro-organisms. 

All  bacteria  produce  their  specific  effects  through  the  action  of  their 
excreta,  or  by  virtue  of  the  injurious  action  of  certain  chemical  com- 
pounds existent  in  their  bodies.  The  variety  of  these  chemical  com- 
pounds is  very  great.  Many  bacteria  excrete  products  peculiar  to 
themselves — chemical  bodies  often  of  definite  composition  and  of  well- 
characterized  physiological  properties. 

When  saprophytes  grow  upon  or  within  the  body  under  such  con- 
ditions that  their  poisonous  products  are  absorbed  into  the  system,  we 
speak  of  the  complexus  of  resulting  symptoms  as  sapremia.  Clinically 
it  is  most  difficult  to  separate  cases  of  pure  sapremia  from  cases  of 
suppuration  and  septicemia.  Besides  this,  mixed  infections  are  especi- 
ally likely  to  occur  under  those  conditions  in  which  putrefaction  occurs. 
Nevertheless,  there  are  a  few  classical  forms  of  sapremia  which  can  be 
fairly   well   recognized   clinically.     After  childbirth,   for  example,   the 


144  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

uterus  may  be  regarded  as  a  wounded  viscus.  The  placental  site  is 
the  wound-surface  proper,  which  can  freely  absorb  poisonous  matter 
from  the  uterine  cavity.  If,  now,  a  portion  of  the  placenta  or  of  the 
fetal  membranes  is  not  expelled,  and  chances  to  become  infected  with 
germs  of  putrefaction  introduced  through  the  vagina,  the  conditions  for 
the  growth  of  the  saprophytes  are  well-nigh  ideal.  Resorption  takes 
place  with  great  freedom.  Large  quantities  of  noxious  matter  are  very 
rapidly  introduced  into  the  system  at  large  and  produce  symptoms  of 
poisoning.  If  the  poisons  are  not  of  sufficient  quantity  or  of  proper 
kind  to  cause  rapid  death  from  toxemia  (and  this  termination  is  un- 
common), the  offending  mass  of  dead  tissue  may  be  removed  by  the 
attendant's  art,  with  immediate  cessation  of  the  symptoms.  A  patient 
suffering  from  strangulated  hernia  encounters  the  risks  of  sapremia 
from  multiplication  of  intestinal  saprophytes  in  the  strangulated  tissues, 
although  the  action  of  the  more  aggressive  attendant  micro-organisms 
is  often  much  more  portentous.  It  is  possible,  also,  for  the  blood-clots 
and  wound-secretions  of  any  open  wound  to  putrefy  and  produce  a 
condition  analogous  to  that  of  intra-uterine  putrefaction. 

The  poisons  in  action  are  of  varied  composition  and  of  unequal 
toxicity.  Many  of  the  ptomains  of  putrefaction  have  already  been 
isolated  and  experimentally  studied. 

The  symptoms  vary  with  the  quantity  of  dead  tissues  to  be  acted 
upon,  the  peculiarities  of  the  infecting  micro-organism,  and  the  rapid- 
ity of  resorption.  We  may  say,  in  a  word,  that  the  symptom-complex 
is  that  of  progressive  poisoning  by  nerve-depressing  and  fever-exciting 
agents.  A  chill,  of  course,  occurs  in  those  cases  in  which  the  tern- 
perature  rises  to  1020  or  1040  F.,  as  is  often  the  case.  This  chill,  which 
is  frequently  the  first  sign  of  grave  disturbance,  is  usually  preceded  by 
a  slight  rise  in  temperature,  malaise,  headache,  anorexia,  and  a  coated, 
dry  tongue.  The  pulse  grows  more  frequent  and  soft  as  the  tempera- 
ture rises.  Vomiting,  diarrhea,  scanty,  high-colored  urine,  and  head- 
ache are  succeeded,  as  the  poisoning  deepens,  by  restlessness,  delirium, 
jactitation,  and  cold  perspiration.  At  last,  as  death  approaches,  the 
pulse  grows  weaker,  involuntary  passages  of  urine  and  feces  occur, 
and  delirium  is  replaced  by  coma. 

Should  the  amount  of  culture-medium  be  quite  limited  (blood-clot, 
placenta,  or  other  devitalized  tissue),  the  microbes  may  exhaust  their 
supply  of  pabulum,  and  the  patient  may  recover  without  more  ado. 
But,  clinically,  the  pus-microbes  are  so  commonly  in  association  with 
the  saprophytes  that  usually  only  a  gradual,  instead  of  a  sudden,  re- 
gression of  symptoms  occurs,  with  a  residuum  of  suppuration,  requir- 
ing a  greater  or  less  amount  of  time  to  disappear.  Typical,  sudden, 
and  gratifying,  however,  is  the  recovery  when,  in  one  of  the  unusual 
cases  of  typical  saprophytic  toxemia,  the  putrefying  placenta  is  ex- 
tracted from  the  uterine  cavity.  The  temperature  falls  within  a  few 
hours  and  all  other  outward  signs  rapidly  disappear. 

The  prognosis  of  sapremia,  then,  depends  upon  the  exhaustion 
of  the  culture-medium  or  its  mechanical  removal.  Uncomplicated 
cases  usually  recover ;  but  it  is  possible  for  the  system  to  be  over- 
powered in  a  few  hours  by  the  ptomains  of  putrefaction  rapidly  poured 
into  the  blood. 


SEPTIC  INTOXICATION.  1 45 

So  unusual  are  these  purely  sapremic  cases,  and  so  difficult  is  it  to 
exclude  clinically  the  noxious  presence  of  other  bacteria,  that  some 
writers  (Kocher  and  Tavel)  would  discard  the  term  sapremia  from  our 
nosology.  The  diagnosis  must  be  based  upon  the  symptoms  men- 
tioned coming  on  a  few  hours  or  days  after  a  trauma,  with  the  added 
consideration  of  the  local  findings.  The  wound  in  such  cases  will  pre- 
sent some  evidences  (redness,  swelling,  heat,  pain)  of  inflammation  and 
a  discharge  of  thin  acrid  serous  or  serosanguinolent  fluid  from  the 
wound.  The  discharge  is  usually  malodorous ;  but  it  must  be  borne 
in  mind  that  well  marked  cases  of  toxemia  and  sapremia  may  be 
induced  by  the  growth  of  microbes  which  do  not  elaborate  putrid 
products.  A  sour  or  rotten  odor  will  usually  be  noted,  however,  and 
foul-smelling  gases  may  be  given  off. 

The  treatment  is  first,  of  course,  prophylactic ;  careful  antisepsis 
or  asepsis  will  always  prevent  this  wound-complication  in  wounds 
made  by  the  surgeon.  Once  the  condition  is  established,  it  may 
usually  be  cut  short  by  removing  culture-matter,  establishing  drainage, 
and  frequently  irrigating  the  wound  with  a  suitable  antiseptic  solution. 


SEPTIC  INTOXICATION. 

Closely  related  to  sapremia  (which  we  have  described  as  a  toxemia 
of  saprophytic  origin)  is  septic  intoxication,  a  disease  due  to  the  resorp- 
tion of  poisons  from  foci  of  suppuration.  That  the  by-products  of  the 
pus-microbes  cause  profound  local  systemic  disturbances,  when  injected 
into  the  healthy  animal  body,  was  proved  long  ago  by  direct  experi- 
mentation. 

Leber,  as  long  ago  as  1879,  in  studying  aspergillus  keratitis,  reached  the  conclusion  that 
the  micro-organism  must  produce  some  soluble  chemical  bodies  which,  by  diffusion  through 
the  tissues  of  the  cornea,  brought  about  the  widespread  inflammation  noted.  At  a  later 
date  also  (1888)  he  published  an  account  of  a  crystalline  pyogenic  body,  which  he  called 
phlogosin,  derived  from  pure  cultures  of  pus-microbes.  Other  observers  have  found  that 
the  cells  of  many  bacteria  contain  proteids  capable  of  causing  non-progressive  (aseptic) 
suppuration  and  of  seriously  affecting  the  general   system  when  injected  into  cellular  tissue. 

The  resorption  of  toxic  chemical  bodies  from  foci  of  localized  sup- 
puration is  dependent  upon  a  variety  of  conditions.  Granulation-tissue 
does  not  readily  absorb  chemical  bodies,  since,  as  Billroth  long  ago 
pointed  out,  the  granulation-tissue  closes  up  the  lymphatic  spaces. 
The  destruction  of  this  granulation-tissue  barrier  is  sometimes  followed 
by  a  rapid  rise  of  temperature.  Pressure  within  an  unopened  abscess 
is  responsible  for  almost  all  the  resorption.  The  pus-poisons  are  re- 
sorbed  readily  even  by  granulations  when  under  pressure.  Drainage 
of  abscess-cavities  has  for  its  object  the  removal  of  this  pressure ;  if  it 
were  not  so,  the  fever  would  remain  high  even  after  drainage  is  estab- 
lished, since  the  wound-surface  continues  to  be  bathed  in  pus.  This 
is  proved  by  the  fact  that  the  temperature  rapidly  rises  when  pressure 
is  re-established  in  the  abscess-cavity  by  plugging  the  drainage-open- 
ing. Often  a  patient  suffering  from  abscess-formation  has  a  higher 
temperature  for  a  few  hours  after  the  opening  of  the  abscess  than  he 
had  when  the  pressure  was  at  its  height.  This  is  due  to  the  opening 
of  lymph-spaces  to  resorption,  by  the  surgeon's  incision.  Pressure  has 
10 


I46  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

another  effect  on  the  process  of  septic  intoxication — that  of  favoring  the 
spread  of  the  infection  into  remote  tissues,  thus  increasing  at  once  the 
absorbing  area  and  the  amount  of  the  poisons  capable  of  being 
resorbed. 

Not  only  are  the  toxic  substances  elaborated  by  pyogenic  organ- 
isms capable  of  producing  temperature-elevation,  but  the  bodies  of  the 
bacteria  themselves  are  equally  poisonous.  The  bacteria  destroyed 
in  the  contest  with  the  tissues  therefore  add  to  the  septic  intoxi- 
cation. 

We  speak  clinically  of  intoxication  when  we  have  to  deal  with  a 
systemic  poisoning  of  pyogenic  origin,  in  which  there  is  reason  to 
believe  bacteria  from  the  infected  site  have  not  found  their  way  to 
distant  seats  or  into  the  circulating  blood  itself.  We  feel  especial 
confidence  in  such  a  diagnosis  after  we  have  excluded  the  possi- 
bility of  septicemia  by  affording  drainage  to  the  abscess  and  after  we 
have  found  that  all  evidences  of  toxemia  are  thus  caused  to  dis- 
appear. 

The  degree  of  intoxication  does  not  depend  in  given  cases  of  septic 
poisoning  upon  the  quantity  of  pus  present.  A  small  amount  of  pus, 
even  a  drop  or  two,  under  the  periosteum,  for  example,  may  cause  more 
violent  symptoms  than  a  half-pint  under  the  looser  parts  of  the  skin. 
The  toxicity  also  depends  on  the  character  of  the  cultures  from  which 
the  inoculation  was  made.  Infections  from  exceptionally  virulent  cult- 
ures give  rise  to  much  greater  disturbance  than  those  from  weaker 
growths  of  the  same  bacterium.  No  doubt  the  lymphatic  apparatus 
reacts  to  the  toxins  of  pyogenic  bacteria  somewhat  as  it  does  to  the 
bacteria  themselves,  as  will  be  presently  described  (Halban). 

The  clinical  course  of  septic  intoxication  is  the  clinical  course  of 
the  systemic  reaction  in  local  suppuration.  A  furuncle  will  often  dis- 
charge into  the  blood  quantities  of  toxins  sufficient  to  create  great 
systemic  disturbance.  The  temperature  gradually  rises  with  the  growth 
of  the  inflammatory  focus,  so  that  often  in  a  few  hours  it  reaches  1040 
or  1050  F.  Should  a  large  quantity  of  the  toxins  be  suddenly  thrown 
into  the  circulation — i.  c,  when  the  inflammation  is  rapidly  progressive 
and  virulent,  or  when  an  abscess  bursts  into  an  actively  resorptive 
cavity — the  intoxication  will  be  evidenced  by  a  chill  preceding  the  rise 
of  temperature.  In  moderate  intoxications  the  fever-curve  is  fairly 
regular,  being  lower  in  the  morning  than  in  the  evening,  as  a  rule.  The 
elevation  continues  until  the  entire  quantity  of  resorbable  material  has 
been  removed,  as  maybe  the  case  with  small  and  peculiarly  conditioned 
foci,  or  until  the  progressive  spread  of  the  inflammation  with  the  usual 
necrosis  and  liquefaction  of  tissues  in  the  line  of  least  resistance  per- 
mits the  escape  of  the  pus.  If  large  quantities  of  pus-toxins  are  thrown 
rapidly  into  the  circulation,  death  may  result  from  the  sudden  violent 
depression  of  the  vital  powers. 

Septic  intoxication  must  be  clinically  differentiated  from  septicemia, 
according  to  rules  formulated  under  the  heading  Septicemia.  In  all 
forms  of  pyogenic  temperature-elevation  a  septic  intoxication  is  present, 
but  we  must  exclude  septicemia  before  limiting  our  diagnosis  to  septic 
intoxication  alone. 


SEPTICEMIA,   PYEMIA,  AND  SEPTICOPYEMIA.  1 47 

SEPTICEMIA,  PYEMIA,  AND  SEPTICOPYEMIA. 

By  septicemia  we  mean  that  form  of  systemic  poisoning  in  which 
living  bacteria  enter  the  blood.  It  is  necessary  that  the  microbes 
reproduce  themselves  in  the  blood,  and  that  they  be  found  alive  in 
that  fluid,  capable  of  growth  when  planted  upon  suitable  media.  We 
exclude  by  common  consent  those  infections  which  are  not  typically 
pyogenic  in  character  (anthrax,  glanders,  etc.).  Septicemia  is  therefore 
not  necessarily  associated  with  putrefaction. 

Pyemia  no  longer  means,  as  its  etymology  implies,  pus  in  the  blood. 
By  pyemia  we  now  mean  a  form  of  blood-poisoning  by  pyogenic  or- 
ganisms, in  which  living  bacteria  are  transported  by  the  blood-currents 
to  distant  tissues,  where  they  grow  and  produce  abscesses  ;  so  that  in 
pyemia  the  production  of  multiple  abscesses  is  the  typical  pathological 
change,  just  as  in  septicemia  the  dominant  feature  is  the  systemic 
intoxication  with  the  living  bacteria  in  the  blood. 

Septicopyemia  is  a  clinical  term  used  to  convey  the  impression  that 
the  symptoms  of  sepsis  are  marked  as  well  as  those  of  pyemia. 

At  the  present  time,  therefore,  we  do  not  draw  a  sharp  line  between 
these  three  forms  of  pyogenic  disease.  Neither  theory  nor  practice 
would  now  justify  such  a  distinction,  since,  as  the  pathogenic  organisms 
are  the  same  in  each  of  these  conditions,  the  morbid  anatomical 
changes  vary  more  in  degree  than  in  kind,  and  the  clinical  signs  do  not 
enable  us  to  distinguish  unerringly  between  them.  This  inability  to 
separate  these  forms  of  one  disease  has  been  delayed  in  recognition 
because  in  some  of  the  lower  animals  typical  septicemias  are  found — 
i.  c,  the  same  bacterium  injected  into  the  blood  always  produces  the 
same  form  of  septicemic  disease.  In  man  the  pyogenic  microbes  not 
only  produce  septicemia  and  pyemia,  but  also  local  infections  whose 
manifestations  are  often  entirely  distinct  from  any  systemic  disease 
except  a  transitory  intoxication.  We  have  in  man,  then,  no  specific 
micro-organism  of  septicemia  and  of  pyemia.  The  clinical  pictures  of 
these  diseases  are  often  obscured  by  primary  local  disturbances  which 
may  even  prevent  the  unwary  practitioner  from  recognizing  the  sys- 
temic invasion. 

While  it  is  true  that  man's  septicemia  is  not  a  typical  disease,  many 
lessons  and  suggestions  may  be  gained  by  a  study  of  the  typical  sep- 
ticemias of  lower  animals. 

The  classical  research  in  this  department  of  investigation  is  that  of  Koch  on  /)ioitsc  septi- 
cemia ( 1S76),  who  found  that  by  injecting  blood,  which  had  been  allowed  to  putrefy  for  two 
or  three  days,  into  the  cellular  tissue  of  house-mice,  a  mortal  disease  was  produced,  even  when 
only  five  drops  of  the  fluid  were  injected.  Various  forms  of  bacteria  were  found  in  the 
cellular  tissues  of  the  back  where  the  injection  had  been  made.  The  organs  of  the  dead 
animals  were  found  normal  in  appearance,  and  this  fact,  taken  in  conjunction  with  the  fact 
that  the  mouse  lived  only  four  or  five  hours,  led  Koch  to  think  the  cause  of  death  was 
toxemia  and  not  septicemia.  He  then  injected  another  series  of  mice  with  smaller  doses — 
one  to  two  drops.  The  majority  of  the  infected  animals  lived  ;  but  a  few  died  in  about 
twenty-four  hours.  The  latter  at  first  developed  a  conjunctivitis  ;  then  the  movements  of 
the  animal  became  more  slow,  the  back  became  arched,  and  the  extremities  drawn  up. 
Anorexia  set  in,  respiration  became  very  slow,  and  vital  depression  ended  in  death.  The 
same  effect  was  obtained  with  one-tenth  of  a  drop  of  the  liquid,  death  occurring  forty  or 
fifty  hours  after  the  injection.  After  death  the  animal  remained  in  the  same  position.  At 
the  autopsy  the  organs  appeared  normal,  but  the  spleen  seemed  a  little  enlarged.  If  now 
one-tenth  of  a  drop  of  blood  from  the  dead  mouse  was  used  to  inoculate  a  healthy  animal, 
the  same  disease  developed  and  the  mouse  died  in  fifty  hours.      In  his  first  publication  on 


148  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

this  subject,  Koch  reported  54  mice  successively  inoculated  with  the  septicemia  ;  so  that  no 
doubt  could  be  entertained  in  regard  to  the  bacterial  character  of  the  disease  or  its  deadly 
activity.  The  bacteria  were  seen  with  difficulty,  until  Abbe's  condenser  and  good  one- 
twelfth-inch  objectives  were  used.  They  were  found  to  be  minute  bacilli.  The  bacteria 
were  proved  to  exist  and  to  thrive  in  the  blood,  since  the  blood  always  showed  the  bacteria 
without  regard  to  the  vessel  from  which  it  was  drawn. 

These  pyogenic  microbes  seemed  to  retain  their  virulence  unimpaired 
throughout  many  generations.  In  man,  the  organisms  are  of  widely 
varying  virulence,  and  may  be  introduced  under  varying  circumstances 
which  either  favor  or  militate  against  their  growth.  Their  numbers  may 
be  great  or  small,  so  that  they  are  sometimes  defeated  in  their  contest 
with  the  tissues,  and  at  other  times,  when  in  great  number,  may  produce 
a  frankly  local  process  or  one  of  a  spreading  character.  Consequently 
there  is  no  pus-microbe,  the  injection  of  a  culture  of  which  will  produce 
in  all  cases  a  septicemia  in  man.  We  must  hasten  to  add  that  we  do 
not  as  yet  know  all  the  conditions  which  are  required  in  order  to  pro- 
duce septicemia.  Some  of  the  favoring  conditions  are  known  and  these 
will  be  presently  discussed. 

Some  authors  (Monod  and  Macaigne)  distinguish  between  a  primary  and  a  secondary 
septicemia,  the  former  being  that  in  which  only  an  insignificant  point  of  entrance  is  noted, 
the  latter  that  in  which  much  inflammatory  disturbance  exists  at  the  points  of  entrance  of  the 
microbes  into  the  body. 

The  dissemination  of  pus-microbes  from  the  point  of  entry  into  the 
blood  has  been  the  object  of  much  study.  In  the  case  of  the  primary 
septicemia  mentioned — usually  instances  in  which  an  inoculation  of 
very  virulent  bacteria  has  been  effected — the  micro-organisms  may  be 
carried  with  great  rapidity  into  the  blood,  conceivably  by  direct  intro- 
duction into  the  capillary  vessels  in  the  case  of  traumatism,  but  usually 
by  the  lymphatic  route. 

Halban,  whose  researches  on  the  lymph-glands  in  pus-infection  will  be  presently  dis- 
cussed in  detail,  denies  the  occurrence  of  bacterial  transmission  by  blood-currents  from  the 
bleeding  wounds.  In  addition  to  arguments,  he  presents  the  records  of  simple  but  seemingly 
crucial  experiments.  Rabbits  were  wounded  in  one  of  their  legs  and,  while  the  wound  was 
bleeding,  a  dose  of  a  virulent  culture  of  anthrax  bacilli  was  wiped  off  upon  the  wound.  The 
animals  not  treated  died  in  twenty-four  or  thirty-six  hours  ;  but  when  the  leg  was  amputated 
at  the  shoulder-joint  two  or  two  and  one-half  hours  after  the  infection,  death  did  not  occur. 
This  proves  that  the  infection  was  arrested  for  two  hours  in  the  leg,  and  as  the  lymph-glands 
showed  abundance  of  bacilli,  it  is  evident  that  Schimmelbusch  is  mistaken  in  assuming  that 
pathogenic  bacteria  pass  directly  into  the  blood  in  the  infection  of  bleeding  wounds. 

As  is  well  known,  the  chemotactic  power  of  the  pus-microbes  is 
very  great — that  is,  the  leukocytes  are  attracted  toward  these  bacteria 
with  especial  force.  The  bacteria  are  often  enclosed  by  the  leukocytes, 
and,  if  alive  when  thus  taken  up,  as  maintained  by  Metschnikoff,  they 
may  retain  their  vitality  even  when  transported  in  this  way  to  great  dis- 
tances. That  living  bacteria  do  pass  into  the  blood  by  way  of  the 
lymph-passages  has  been  frequently  demonstrated ;  and  their  direct 
introduction  into  the  lymph-spaces  by  open  wounds  favors  this  mode 
of  transmission  very  greatly. 

Leaving  out  of  present  consideration  their  initial  local  effects,  many 
of  the  bacteria  deposited  in  the  lymph-spaces  are  quickly  carried  to  the 
nearest  lymphatic  glands  ;  or  sometimes  they  may  set  up  a  more  or 
less  violent  lymphangitis.  This  inflammation  may  be  limited  to  redness 
and  tenderness  indicating  the  lines  followed  by  the  lymph-vessels,  or  it 


SEPTICEMIA,    PYEMIA,   AND   SEPTICOPYEMIA.  I49 

may  be  of  a  suppurative  character,  in  which  case  one  or  more  abscesses 
will  develop  in  the  course  of  the  lymphatics. 

When  granulations  are  present,  the  older  and  more  highly  differen- 
tiated tissue  of  the  body  is  protected,  as  Billroth  argued  and  as  Leber 
has  so  well  demonstrated,  by  a  wall-like  aggregation  of  leukocytes,  new 
connective-tissue  corpuscles,  and  attendant  new  blood-vessels.  The 
lymph-spaces  are  therefore  closed  toward  the  wound,  and  before  they 
can  be  opened  the  granulation-tissue  wall  must  be  broken  down.  This 
is  well  illustrated  by  the  well-known  clinical  fact  that  probing  an  old 
sinus  will  often  cause  an  erysipelas  to  develop — that  is,  the  probing 
causes  a  lesion  of  the  granulation-tissue  wall  through  which  the  bacteria 
enter. 

W.  Noetzel  has  recently  experimented  upon  this  subject.  He  denuded  large  surfaces  or 
made  deep  pockets  in  the  backs  of  sheep  and  packed  or  dressed  them  with  sterile  gauze. 
When  healthy  granulations  had  been  established,  experiments  with  microbes  and  toxins  were 
instituted.  As  inoculation  material,  cultures  of  splenic  fever  bacillus  were  used,  and  since 
the  sheep  is  highly  susceptible  to  anthrax,  the  entrance  of  the  bacilli  into  the  blood  would  be 
proved  by  the  animal's  death  from  that  disease.  In  no  case  when  bacteria  were  spread  upon 
the  intact  granulations  was  an  inoculation  effected.  Control-animals  inoculated  with  a 
smaller  number  of  bacteria  and  over  a  much  smaller  surface  of  a  fresh  wound  died  in  thirty 
hours.  When  the  granulations  were  injured  during  the  dressings  the  anthrax  bacilli  found 
entrance,  causing  the  animal's  death.  Billroth  had  performed  practically  the  same  experi- 
ment, instituting  granulating  wounds  on  the  backs  of  dogs  and  applying  pus  from  suppurating 
human  wounds  upon  the  granulating  surface.  Xo  reaction  followed  ;  but  when  the  pus 
was  applied  to  a  fresh  wound,  symptoms  of  intoxication  and  septicemia  soon  developed. 

The  relation  of  the  lymphatic  glands  to  the  resorption  of  bacteria  from 
the  cellular  tissues  is  most  important.  It  is  generally  conceded  that 
the  function  of  the  lymphatic  nodes  is,  so  far  as  infection  is  concerned, 
to  filter  out  and  destroy  bacteria.     They  act  also  upon  bacterial  toxins. 

The  recent  studies  of  Josef  Halban  (1897)  have  added  much  to  our  knowledge  of  this 
subject  and  are  worthy  of  consideration. 

When  the  yellow  pus-microbe  was  introduced  into  the  leg-tissues  of  an  experimental  ani- 
mal, varying  periods  elapsed  before  the  bacteria  were  demonstrable  in  the  regional  glands, 
depending  first  upon  the  mode  of  introduction.  If  the  bacteria  were  not  suspended  in  fluid, 
but  were  rubbed  into  the  subcutaneous  tissue,  they  did  not  appear  in  the  glands  until  four 
hours  had  elapsed,  a  circumstance  due  to  the  lack  of  fluid  which  enabled  the  microbes  to  be 
taken  up  quickly  by  the  lymphatics.  Again,  the  site  of  the  injection  was  found  to  be  impor- 
tant. If  the  fluid  was  introduced  into  the  muscular  tissue,  the  bacteria  were  discovered  in 
the  glands  at  the  end  of  one  hour.  Muscular  activity  was  considered  an  active  agent  in 
causing  a  rapid  movement  of  the  microbes  into  the  lymphatic  vessels. 

More  surprising  and  novel  was  the  demonstration  that  some  kinds  of  bacteria  could  be 
found  in  the  glands  much  sooner  than  others.  Thus,  the  Micrococcus  prodigiosus  was  dem- 
onstrable in  the  regional  glands  a  few  minutes  after  injection  ;  the  Staphylococcus  pyog- 
enes in  one  hour,  and  the  anthrax  bacillus  only  after  two  and  one-half  hours.  Halban 
explains  this  difference  by  arguing  that  the  microbes  are  attacked  with  varying  energy  by 
the  glands,  so  that  those  micro-organisms  which  are  slightly  or  not  at  all  influenced  are 
rapidly  demonstrable,  while  those  energetically  destroyed  are  demonstrable  only  after  they 
have  overcome  the  resisting  power  of  the  gland.  Halban  showed,  furthermore,  that  the 
pathogenic  bacteria  are  demonstrable  much  later  than  the  non-pathogenic,  and,  in  addition, 
that  the  more  virulent  the  microbe,  the  more  slowly  was  it  susceptible  of  demonstration. 

When  the  bacteria  gain  entrance  to  the  glands,  they  are  demonstrable  at  first  in  small 
number,  increase  in  number  rapidly,  reach  a  maximum,  again  numerically  diminish,  and 
finally  disappear.  After  the  microbes  have  once  appeared  in  the  glands,  one  or  two  hours 
at  most  elapse  until  they  have  disappeared.  There  is  now  a  latent  period  in  which,  for 
five  or  seven  hours,  absolutely  no  micro-organisms,  or  in  unusual  cases  50  or  60  bacteria, 
are  discoverable  in  the  regional  glands.  After  this  latent  period,  the  bacteria  again  appear 
as  before,  a  maximum  is  reached,  the  number  diminishes,  and  at  length  they  disappear 
again.  This  series  of  changes  can  be  repeated  a  number  of  times,  the  final  outcome  depend- 
ing on  whether  the  bacteria  are  pathogenic  or  not.  The  non-pathogenic  finally  disappear 
entirely  ;  but  the   pathogenic   increase   and   lead  at   last  to  the  death  of  the   animal.      The 


150  INTERNATIONAL    TEXTBOOK  OF  SURGERY. 

alternating  appearance  and  disappearance  of  the  bacteria  represent,  according  to  Halban, 
the  varying  struggle  of  the  bacteria  with  the  bactericidal  elements  of  the  glands.  "  Now," 
says  Halban,  "  if  we  represent  graphically  this  cyclical  appearance  and  disappearance  of 
the  bacteria  by  a  curve  in  which  the  abscissas  indicate  the  time  and  the  ordinates  the  quan- 
tity of  bacteria,  we  obtain  a  curve  which  strongly  recalls  the  temperature-curves  which  we 
are  accustomed  to  see  in  septic  diseases.  And  since  my  later  experiments  have  shown  me 
that  a  certain  congruity  exists  in  the  relations  between  the  internal  organs  and  the  lymph- 
glands,  it  seems  to  me  that  in  this  cyclical  appearance  and  disappearance  of  the  bacteria  in 
the  organs  we  have  an  experimental  basis  for  understanding  the  remarkable  fever  relations 
in  septic  diseases." 

Another  striking  fact,  susceptible  of  easy  clinical  verification,  is  experimentally  demon- 
strated by  Halban.  The  glands  respond  to  infection  by  a  rapid  increase  in  their  lymphoid 
substance.  After  ten  days'  local  infection  with  Staphylococcus  pyogenes,  the  volume  of  the 
regional  glands  is  augmented  twenty  or  twenty-five  times,  without  any  microscopical  change 
except  the  increase  in  the  lymphoid  substance.  Halban  adds  that,  in  spite  of  the  presence 
of  a  local  abscess,  the  staphylococci  in  the  enlarged  regional  glands  are  scarce  (sometimes 
200).  Hence  he  concludes  that,  with  the  increase  in  the  number  of  bacteria  gaining  en- 
trance into  the  lymphatic  vessels,  the  glands  themselves  increase  in  size  until  they  are  able 
to  cope  with  the  microbic  enemies  and  prevent  their  growth  in  the  gland-substance.  That 
the  non-pathogenic  bacteria  pass  through  the  lymphatic  glands  is  proved  by  the  fact  that 
they  were  found  in  the  viscera  a  few  minutes  after  injection  ;  but  the  pathogenic  organ- 
isms made  their  appearance  there  only  when  many  hours  had  elapsed  after  they  had  been 
observed  in  the  lymph -glands. 

Pyogenic  bacteria  once  introduced  into  the  blood  may  grow  there 
and  increase  in  number,  producing  septicemia ;  they  and  their  products 
may  be  killed  or  neutralized  in  the  blood  by  the  action  of  the  chemical 
bodies  called  by  Buchner  sozins  and  alexins,  and  by  the  leukocytes ; 
they  may  be  deposited  in  various  distant  structures,  where  they  become 
locally  active  and  institute  pyemia;  they  may  be  destroyed  by  the  tissue- 
cells  of  the  parenchymatous  organs — liver,  spleen,  bone-marrow,  etc. ; 
or,  finally,  they  may  be  excreted  in  a  living  state  by  the  glandular 
excretory  organs. 

Pathologists  are  now  inclined  to  regard  the  pyogenic  staphylococci 
as  the  organisms  most  frequently  engaged  in  metastatic  suppurative 
processes,  while  the  streptococci  are  thought  to  limit  their  activity 
more  closely  to  regional  inflammation.  Nevertheless,  there  are  some 
clinicians  (v.  Bergmann)  who  strongly  oppose  the  notion  that  we  can 
legitimately  separate  the  micro-organisms  in  this  way.  For  the  present 
we  must  forego  the  temptation  to  draw  hard  and  fast  lines  between  the 
septic  effects  produced  by  these  great  pyogenic  groups. 

The  gonococci  are  now  proved  to  be  capable  of  producing  not  only 
local  but  metastatic  pyogenic  effects.  Wertheim  has  shown,  by  careful 
microscopic  examination  of  an  excised  piece  of  bladder  mucous  mem- 
brane from  a  case  of  gonorrheal  cystitis,  that  "  in  the  epithelium  and 
connective  tissue  an  extraordinary  number  of  gonococci  were  present. 
In  the  submucous  tissue  there  was  a  considerable  number  of  capillaries 
and  very  small  vessels  filled  with  gonococci,  partly  degenerated  and 
partly  well  preserved.  In  many  places  there  was  complete  obstruc- 
tion of  the  lumen ;  in  others  a  mural  projection  was  seen.  The  gono- 
cocci were  found  only  in  capillaries  and  in  the  precapillary  veins,  while 
the  arteries  were  free."  Prof.  Jadassohn  adds  that  in  this  way  it  is 
shown  that  metastases  of  the  gonorrheal  process  can  occur,  and  that, 
too,  through  a  true  gonorrheal  thrombophlebitis.  That  the  joints  in 
gonorrheal  rheumatism  contain  gonococci  has  been  proved  by  numer- 
ous cultural  as  well  as  bacterioscopic  examinations.  Welch  has  shown 
that  endocarditis  in  association  with  other  pyemic  morbid  changes  may 


SEPTICEMIA,    PYEMIA,   AND   SEPTICOPYEMIA.  1 5  I 

be  due  to  the  action  of  gonococci.  Gonorrheal  arthritides  and  the 
associated  visceral  pyogenic  lesions  are  to  be  regarded  as  expressions 
of  true  gonorrheal  pyemia. 

Not  only  gonorrheal  rheumatism  but  also  acute  rheumatic  poly- 
arthritis is  to  be  regarded  as  of  a  septic,  if  not  pyemic,  character. 
Numerous  observers  (Guttmann,  Sahli,  Barbier)  have  found  pyogenic 
cocci  in  the  joints  in  acute  rheumatism  ;  but  no  specific  organism  has 
thus  far  been  found.  The  fact  that  an  angina  has  preceded  many  cases 
of  the  disease  (older  writers,  and  later  Buss,  Eichhorst,  Jaccoud)  has 
seemed  to  lend  probability  to  the  infection  theory  by  supplying  a  dem- 
onstrated atrium.  Then,  again,  the  clinical  signs  are  typical  of  a 
metastatic  affection,  and  the  post-mortem  findings — cloudy  swelling  of 
the  myocardium,  liver,  and  spleen,  and  the  frequent  endocarditis — seem 
to  point  with  conclusiveness  to  the  pyemic  character  of  the  malady. 
For  the  present,  however,  we  await  further  bacteriological  study  of 
the  disease. 

Pathological  Anatomy. — In  those  violent  cases  of  sepsis  in 
which  death  takes  place  within  a  few  hours  after  the  infection,  a  careful 
anatomical  study  of  the  tissues  at  the  autopsy  may  reveal  no  lesions 
and  may  fail  to  throw  light  on  the  nature  of  the  disease.  Dependence 
is  then  to  be  placed  upon  the  discovery  of  the  active  pathogenic  agents 
by  cultural  methods,  using  material  from  the  blood,  the  bone-marrowr, 
and  the  viscera,  while  the  clinical  history  has  often  to  be  utilized  in 
making  up  the  diagnosis,  especially  where  no  infection  atrium  can  be 
found.  But  if  the  disease  has  not  been  so  quickly  fatal,  if  the  toxins 
set  free  by  the  micro-organisms  have  had  time  to  act,  and  if  ele- 
vated temperature  has  for  a  time  exercised  its  influence  upon  the  body, 
many  of  the  tissues  will  present  evidences  of  cloudy  swelling  or  even 
of  fatty  degeneration.  We  are  told  in  the  text-books  on  pathological 
anatomy  and  clinical  medicine  to  expect  an  enlarged  spleen.  But  the 
spleen  is  often  of  ordinary  size,  even  in  cases  in  which  the  blood  find- 
ings are  positive  (M.  Hahn).  The  spleen  when  enlarged  constitutes 
often  a  palpable  mass  in  the  left  hypochondrium,  and  is  often  referred 
to  clinically  as  an  acute  splenic  tumor  or  swelling.  On  pressure,  the 
pulp  yields  readily  to  the  finger,  and  inspection  shows  a  minimum  of 
connective  tissue.  A  large  quantity  of  blood  in  the  organ  helps  to 
give  the  tissue  a  bright  red  appearance.  The  marrow  of  the  long 
bones  is  similarly  softened,  redder  than  usual,  and  congested  (Kolisko). 
It  will  be  seen  that  these  indirect  or  remote  changes  are  not  peculiar  to 
pyogenic  disease,  but  are  common  to  the  acute  infections. 

Much  more  characteristic  are  the  morbid  alterations  which  follow 
in  the  direct  track  of  the  infection.  At  the  infection  atrium  nothing 
may  be  found — a  few  hours  may  suffice  for  the  closure  and  obliteration 
of  the  wound  (e.  g.,  a  hypodermic  puncture).  Sepsis  taking  origin  in 
this  way  is  clinically  known  as  a  cryptogenetic  or  spontaneous  infection. 

Leube  has  described  a  number  of  such  cases  and  has  laid  down  rules  for  their  diagnosis  ; 
but  usually  a  local  lesion  will  be  noted — a  simple  abscess,  a  spreading  phlegmonous  inflam- 
mation, or  a  focus  of  suppuration  under  pressure.  Kocher  calls  attention  to  the  fact  that 
systemic  infection  is  more  likely  to  occur  when  the  bacteria  at  the  primary  site  of  disease 
have  had  to  grow  against  much  cellular  resistance.  In  this  way,  if  the  bacteria  overcome 
the  tissues,  they  will  have  a  heightened  virulence.  Kocher  cites  cases  from  his  own  prac- 
tice in  which  the  osteomyelitic  form  of  pyemia  occurred  after  such  primary  infections. 


152  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

A  carbuncle  is  especially  prone  to  produce  septicemia  because  the 
toxins  of  the  pus-microbes  are  forced  rapidly  into  the  circulation  and 
because  the  bacteria  themselves  can  easily  pass  into  the  lymphatics  or 
even  into  small  veins. 

When  extensive  surfaces  capable  of  very  rapid  absorption  are  sud- 
denly flooded  with  infected  fluids,  acute  toxemia  is  likely  to  result  very 
quickly  in  death.  An  example  of  such  a  morbid  anatomical  catas- 
trophe is  to  be  found  in  the  rupture  into  the  abdominal  cavity  of  a  gall- 
bladder distended  with  pus  or  mucopurulent  fluid.  But  when  acute 
chemical  poisoning  is  withstood,  the  system  is  swept  with  bacteria, 
which,  by  way  of  the  blood,  are  carried  in  a  few  minutes  to  all  parts  of 
the  body.  These  organisms  may  be  demonstrated  then  in  the  blood 
and  in  the  parenchymatous  viscera. 

The  present  consensus  of  opinion  among  bacteriologists  is  that  the 
streptococcus  of  Fehleisen,  which  was  once  thought  to  be  the  specific 
microbe  of  erysipelas,  is  capable  of  producing  suppuration.  This 
means  it  is  identical  with  Streptococcus  pyogenes.  Petruschky  reports 
a  number  of  cases  in  which  the  same  organism  was  cultivated  from  the 
erysipelatous  skin  and  from  abscesses  in  the  same  patient,  evidently 
anatomically  connected  with  the  dermatitis.  Erysipelas  has  long  been 
recognized  as  a  fruitful  source  of  blood-poisoning.  Many  observers 
have  shown  that  during  attacks  of  erysipelas,  streptococcus  abscesses 
occur,  and  that  these,  as  well  as  other  forms  of  septic  disease,  are 
common  either  in  the   course  of  erysipelas   or  as  sequelae. 

The  changes  taking  place  in  the  lymphatic  vessels  engaged  in 
carrying  pyogenic  organisms  from  an  infection  atrium  may  be  so  slight 
that  no  clinical  or  post-mortem  change  can  be  made  out.  But  a 
lymphangitis  often  occurs — indicated  clinically  by  red  lines  widening 
here  and  there — running  over  the  skin  if  the  inflammation  be  near  the 
surface  of  the  body,  and  converging  toward  the  lymphatic  glands  of 
the  region.  This  lymphangitis  may  become  locally  violent  and  termi- 
nate in  suppuration.  The  vessel  then  becomes  the  center  of  an  abscess. 
Such  abscesses  may  form  in  numbers  along  the  course  of  the  lym- 
phatic vessels.  As  a  rule,  however,  the  bacteria  proceed  to  the  re- 
gional glands  without  suppurative  lymphangitis.  The  morbid  changes 
in  the  glands  we  have  already  described  for  those  instances  in  which 
suppuration  fails.  It  is  always  possible,  however,  that  a  flood  of 
microbes  may  be  carried  to  the  regional  glands  by  the  lymphatic 
vessels  with  such  rapidity,  and  in  association  with  so  much  bacterial 
poison,  that  the  cells  are  unable  to  dispose  of  them.  Suppurative 
lymphadenitis  will  then  be  found.  In  the  cut  section  of  the  glands 
small  isolated  abscesses  may  be  noted  located  in  the  midst  of  the  pulp, 
or,  at  a  later  stage,  the  gland-capsule  may  contain  nothing  but  a  broken- 
down  mass  of  shreddy  tissue  mixed  with  pus.  Naturally,  such  glands 
are  not  only  incapable  of  further  protecting  the  system,  but  are  them- 
selves a  menace  to  its  welfare,  constituting  new  foci  of  disease.  The 
resisting  fibrous  capsule  soon  breaks  down  altogether  at  some  point, 
and  the  pus,  escaping  into  the  loose  areolar  tissue,  forms  abscesses 
{peri-adenitis). 

Once  the  microbes  have  passed  the  lymphatic-gland  barrier,  they 
are  poured  with  the  lymphatic  current  into  the  blood.     Swiftly  they 


Plate  £. 


Infiltration  of  muscular  tissue  with  streptococci  in  a  case  of  septicemia  of  man.  The 
blood  vessels  contain  numerous  leukocytes,  but  none  are  found  in  the  surrounding  connective 
tissue  (Warren's  Surgical  Pathology). 


U>^ 


Capillary  embolus  of  streptococci  in  a  sarcoma.  A  round-cell  infiltration  is  seen  in  the 
sarcomatous  tissue  about  the  embolus.  (Case  of  fatal  septicemia.)  (Warren's  Surgical 
Pathology.) 


SEPTICEMIA,    PYEMIA,   AND   SEPTICOPYEMIA.  153 

are  borne  to  all  parts  of  the  body,  being  constantly  subject  to  the 
destructive  influence  of  the  leukocytes  and  the  chemical  protective 
bodies  of  the  serum  (sozins  and  alexins  of  Buchner),  until  they  are 
either  destroyed  in  the  blood-current  or  in  the  capillaries  of  the  vis- 
cera (spleen,  liver,  etc.)  and  in  the  red  bone-marrow,  or  are  excreted 
by  the  emunctory  glands.  But  while  they  are  alive  in  the  blood,  they 
may  be  found  clinically  or  post  mortem  by  cultural  methods.  The 
toxins  of  the  bacteria  are  also  to  be  found  in  the  circulating  blood,  as 
we  know  from  Marmorek's  experiments,  in  which  it  was  shown  that 
for  a  month  after  recovery  from  streptococcus  infection,  the  serum  of 
the  animals  used  was  poisonous  to  other  individuals  of  the  same  spe- 
cies. Antitoxins  are  also  developed,  as  already  shown  (Marmorek, 
Petersen  ;  denied  by  Lubarsch). 

A  leukocytosis  (temporary  increase  in  the  number  of  white  blood- 
corpuscles)  is  the  common  result  of  suppuration,  and  occurs  as  well  in 
septicemia  and  pyemia. 

Changes  in  the  blood-vessels  occur  in  both  septicemia  and  pyemia ; 
but  it  is  chiefly  in  connection  with  pyemia  that  the  subject  has  to  be 
considered.  The  micro-organisms  get  into  the  blood  in  two  well- 
recognized  ways :  first,  by  the  lymphatic  route  already  described ; 
second,  by  the  direct  invasion  of  the  blood-vascular  walls.  (The 
direct  entrance  of  pathogenic  organisms  into  the  small  vessels  of 
wounds,  as  upheld  by  Schimmelbusch,  is  denied  by  Halban.) 

When  an  abscess  develops  about  a  vein,  thrombophlebitis  occurs,  the 
process  beginning  in  the  adventitia  of  the  vessel,  which  responds  to 
infection  exactly  as  would  any  other  vascularized  connective-tissue 
structure.  If  drainage  is  not  effected,  the  wall  of  the  vessel  becomes 
more  and  more  inflamed  by  contiguity  of  tissue  until  the  intima  is 
reached.  This  membrane  becomes  swollen  and  ill  nourished,  and  no 
longer  supplies  those  well-recognized  conditions  upon  "which  the  in- 
tegrity of  the  blood  depends — in  other  words,  coagulation  occurs.  It 
is  most  important  to  remember  that  the  thrombus  formed  is  at  first 
aseptic,  and  remains  so  until  bacteria  have  invaded  it  in  the  same  way 
that  the  wall  of  the  vessel  was  attacked — i.  c,  by  contiguity  of  tissue, 
and  not  by  rapid  dissemination  through  fluids.  That  the  thrombus  is 
at  first  aseptic  is  proved  by  the  fact  that  the  emboli  set  free  from 
thrombi  in  the  sinus-phlebitis  of  otitis  do  not  produce  secondary  ab- 
scesses. The  wall  of  the  thrombosed  vessel  is  more  and  more  invaded 
by  the  microbes  until  it  is  broken  down  altogether  at  certain  points. 
In  simple  infections,  purulent  liquefaction  of  the  wall  takes  place,  the 
natural  color  of  the  vessel  giving  place  to  a  dirty  gray,  and  the  thinned 
wall  yielding  at  some  point  to  slight  pressure  of  the  probe.  The  sup- 
purative changes  involve  the  vessel-wall  as  far  as  it  is  surrounded  with 
pus.  The  thrombus  may  extend  only  a  short  distance,  or  it  may 
spread  many  inches  along  the  course  of  the  vessel,  and  may  even  run 
out  into  branches  of  the  chief  vein.  At  first,  as  has  been  said,  the 
thrombus  is  not  infected.  It  is  firm  and  elastic,  and  gives  the  vessel 
a  cord-like  feeling  upon  palpation.  But  when  the  pyogenic  process 
has  liquefied  a  part  of  the  vessel-wall,  the  microbes  flourish  in  the 
coagulated  blood,  which  offers  but  little  mechanical  or  vital  resistance, 
and  speedily  becomes  broken  down  (partly  liquefied)  into  a  semi-fluid 


154  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

mass  in  which  parts  of  the  thrombus  float.  When  no  portion  of  the 
infected  thrombus  intervenes  between  the  broken-down  part  of  the 
vessel's  contents  and  the  fluid  blood,  the  conditions  required  for  the 
occurrence  of  embolism  are  furnished,  masses  of  infected  thrombus  are 
carried  to  distant  viscera,  and  infected  infarcts  are  produced,  resulting 
in  the  formation  of  secondary  or  metastatic  abscesses.  Should  the 
abscess  about  the  vein  be  drained,  and  an  exit  be  afforded  for  the 
broken-down  matter  in  the  vein,  the  suppurative  process  may  be  ar- 
rested, and  the  uninfected  thrombus  may  form  an  effective  temporary 
barrier  to  the  further  spread  of  the  disease  into  the  blood.  This  tem- 
porary barrier  may  be  converted  into  a  permanent  one  by  the  sub- 
stitution of  connective  tissue  growing  from  the  vessel-wall  for  the 
thrombus. 

When  emboli  are  carried  into  the  blood,  they  are  not  arrested  in 
their  course  until  they  reach  a  part  of  the  vascular  tubage  which  has 
a  smaller  diameter  than  that  of  the  embolus.  Their  arrest  is  therefore 
a  mechanical  matter.  Abscesses  may  or  may  not  develop  from  in- 
fected emboli.  The  emboli  may  not  carry  a  sufficient  number  of 
micro-organisms  to  the  point  of  arrest  to  overcome  local  resistance ; 
other  conditions  of  infection,  also,  may  be  absent.  But,  as  a  rule,  the 
conditions  are  highly  favorable  for  infection,  because  the  plugging  of 
the  vessel  produces  an  area  of  imperfectly  nourished  tissue  in  which 
the  microbes  rapidly  flourish.  First,  an  endarteritis  occurs  at  the  site 
of  embolism ;  the  vessel-walls  are  successively  invaded,  this  time  from 
within  outward,  and  the  pus,  having  got  into  the  perivascular  tissue, 
speedily  finds  its  way  about  the  wedge-,  cone-,  or  cylinder-shaped  mass 
of  anemic  tissue.  When  such  a  morbid  anatomical  incident  has  oc- 
curred, a  sphacelus  may  sometimes  be  found  in  parenchymatous  organs, 
surrounded  by  pus.  Should  the  embolism  have  occurred  in  the  bone, 
a  sequestrum  will  be  formed. 

It  is  in  the  bones,  however,  that  localization  of  bacteria  from  the 
blood  is  especially  prone  to  occur  by  the  process  known  as  mural  im- 
plantation. Micro-organisms  floating  in  the  blood,  finding  points  in 
the  smaller  vessels  and  capillaries  where  the  current  moves  but  slowly, 
become  arrested,  and,  together  with  white  corpuscles,  endothelia,  and 
fibrin,  produce  thrombi  in  which  the  bacteria  grow.  Various  circum- 
stances, such  as  anatomical  conformation,  exposure  to  cold  and  trauma, 
furnish  opportunity  for  the  mural  implantation  of  microbes.  Doubtless 
many  such  localizations  result  in  the  death  of  the  bacteria  and  local 
healing ;  but  abscesses  beginning  in  the  endothelium  of  the  vessel  and 
extending  through  the  vessel-wall  into  the  surrounding  tissue  are  very 
commonly  found  in  pyemia. 

The  kidneys  are  especially  prone  to  purulent  inflammations  on 
account  of  the  fact  that  they  excrete  bacteria  (Biedl  and  Kraus). 
These  inflammations  often  affect  the  glomeruli,  in  which  the  circula- 
tion is  slow. 

Of  course,  the  greatest  number  of  emboli  find  lodgement  in  the  lungs, 
since  the  majority  of  vessel-invasions  occur  on  the  venous  side  of  the 
circulation.  But  the  branches  of  the  pulmonary  vessels  are  relatively 
large,  and  many  masses  are  small  enough  to  pass  through  them  into 
the  pulmonary  veins,  which   deliver  them   to  the  systemic  circulation, 


SEPTICEMIA,    PYEMIA,   AND   SEPTICOPYEMIA.  I  55 

through  which  they  are  carried  to  the  remotest  parts  of  the  body.  The 
distribution  and  lodgement  of  emboli,  then,  correspond  in  large  measure 
with  the  distribution  of  the  blood-mass,  many  being  observed  in  the 
liver,  brain,  spleen,  kidneys,  etc. 

Symptoms  and  Course. — The  symptoms  and  course  of  pyogenic 
bacteriemia  are  very  variable,  so  much  so  that,  until  very  recent  times, 
attempts  were  well-nigh  universally  made  to  divide  the  disease  into  a 
number  of  parts  corresponding  to  its  clinical  manifestations.  At  the 
risk  of  some  clinical  confusion  we  are  obliged,  as  we  must  always  do 
when  possible,  to  preserve  the  unity  of  pathology  and  describe  under  a 
single  general  heading  all  the  symptom-groups  of  the  malady. 

Common  to  all  acute  forms  of  pyogenic  bacteriemia  are  certain 
symptoms  already  referred  to  as  due  to  the  resorption  of  toxic  substances 
elaborated  by  the  microbes.  The  circulatory  mechanism  is  usually 
profoundly  affected  by  the  activity  of  these  chemical  substances.  The 
heart's  action  becomes  rapid,  the  tension  of  the  blood  in  the  arterial 
system  is  lowered,  and,  when  fever  and  intoxication  are  at  their  height, 
the  skin  presents  a  bluish  appearance,  due  to  the  stagnation  of  the 
venous  blood.  As  septic  poisoning  deepens,  and  the  bacteria,  over- 
coming local  and  regional  resisting  forces,  migrate  to  distant  parts  of 
the  body,  the  heart  beats  more  and  more  rapidly,  the  pulse  often  run- 
ning up  to  150  and  more  per  minute,  until,  just  before  dissolution,  it 
cannot  be  counted. 

The  temperature-record  is  in  some  forms  of  septicemia  almost  char- 
acteristic, as  we  shall  see.  The  manifest  tendency  in  subacute  sepsis  is 
for  the  temperature,  after  a  sudden  rise  to  1040  F.  or  more,  to  become 
lower  every  morning,  only  to  rise  to  the  maximum  toward  evening.  In 
pyemia  in  its  various  forms,  chills,  often  very  violent,  are  the  outward 
manifestations  of  metastatic  movements  of  the  bacteria,  which  result  in 
the  formation  of  secondary  and  tertiary  abscesses.  When  recovery 
from  sepsis  takes  place,  the  fall  in  temperature  to  normal,  or  almost  to 
normal,  is  often  surprisingly  rapid,  if  the  primary  focus  of  infection  is 
quickly  removed,  as  by  amputation.  When  recovery  is  due  to  slow 
drainage,  the  temperature-curve  returns  gradually  to  the  normal  line, 
but  the  morning  remission  already  mentioned  continues  to  recur.  A 
remarkable  fact,  giving  rise  to  the  greatest  clinical  difficult}',  is  to  be 
found  in  the  circumstance  that  the  temperature-elevation  is  often  slight 
as  compared  with  the  pulse-rate.  In  other  words,  the  pulse-rate  may 
indicate  profound  sepsis,  while  the  temperature  may  be  comparatively 
low.  This  is  due,  it  seems,  to  the  fact  that  certain  pyogenic  organisms 
elaborate  not  only  a  chemical  body  which  elevates  the  temperature,  but' 
one  which  tends  to  lower  it.  The  preponderance  of  the  latter  in  the 
by-products  of  the  micro-organisms  of  a  given  case  lowers  the  tem- 
perature, while  the  heart,  uninfluenced,  beats  rapidly.  This  is  especially 
true  of  certain  forms  of  sepsis  taking  origin  in  abdominal  pyogenic 
affections. 

The  nervous  system  is  at  times  stimulated  by  sepsis,  so  that  the 
patient  does  not  realize  his  own  jeopardy ;  but,  for  the  most  part,  de- 
pression is  noted.  For  the  first  few  days  the  patient  sleeps  much,  is 
roused  with  some  difficulty,  responds  slowly  to  questions,  and  will  lie 
for  hours  in  a  state  of  stupor.     At  first,  the  mind,  though  acting  slowly, 


156  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

is  clear ;  but  later,  hebetude  is  followed  by  stupor,  stupor  by  coma,  and 
coma  by  death. 

The  respiratory  system  is  active  enough  in  the  milder  forms  of  sepsis  ; 
but  a  bluish  tinge  of  the  face  is  usually  seen  as  the  poisoning  deepens, 
proving  that  the  blood  is  but  imperfectly  aerated. 

The  glands  of  the  skin  and  of  the  mucous  membranes  are  not  active 
in  sepsis.  The  tongue  becomes  dry  and  coated  ;  and,  as  the  disease 
advances  and  deepens,  becomes  marked  by  reddening  of  the  edges, 
pointing  of  the  tip,  and  the  collection  of  sordes  upon  the  dorsum. 
Perspiration  is  often  profuse,  and  the  loss  of  a  considerable  volume  of 
water  in  this  way  may  cause  a  temporary  feeling  of  depression.  Since 
bacteria  are  known  to  be  excreted  by  the  sudoriparous  glands,  the  use 
of  violent  sudorifics  has  been  proposed  as  a  therapeutic  measure  in 
sepsis;  but  the  injurious  effects  of  these  agents  on  other  functions  has 
prevented  them  from  becoming  popular. 

That  form  of  septicemia  in  which  no  focus  of  suppuration  exists,  but 
in  which  a  fresh  wound  is  infected  with  bacteria  which  seem  to  pass 
rapidly  into  the  blood,  is  sometimes  spoken  of  as  primary  septicemia. 
This  form  is  especially  dreaded  because  of  our  inability  to  guard  against 
it,  from  the  fact  that  the  wound  may  be  an  accidental  one,  that  the 
extreme  virulence  of  the  infection  can  be  known  only  by  the  outcome, 
and  that  treatment  is  usually  of  no  avail.  We  refer  to  those  violent 
forms  of  infection  in  which  the  prick  of  a  pin  or  a  needle  is  followed  by 
death.  Medical  men  are  especially  in  dread  of  such  infections.  In 
making  post-mortem  examinations,  especially  of  fresh  bodies,  inocula- 
tion may  be  effected  through  a  slight  punctured  wound.  The  infectious 
material  is  of  especial  activity  when  it  is  derived  from  fresh  bodies  in 
which  the  microbes  have  flourished  before  death,  so  that  their  virulence 
is  likely  to  be  heightened,  especially  if  they  have  had  to  grow  against 
a  considerable  tissue-resistance,  as  in  peritonitis  or  acute  abscess-forma- 
tion. The  operator  thinks  nothing  of  the  puncture  he  has  received, 
often  does  not  interrupt  his  work  to  dress  the  wound,  and  is  surprised 
a  few  hours  afterward  to  find  himself  suffering  from  a  chill  followed  by 
high  temperature.  A  few  red  lines  running  up  the  arm  to  slightly 
swollen  lymph-glands  call  attention  to  lymphangitis  and  beginning 
lymphadenitis,  and  make  more  certain  the  diagnosis  of  acute  septi- 
cemia. Delirium  followed  by  coma  is  associated  with  all  the  other 
signs  of  violent  depressant  intoxication,  the  pulse  and  respiration  be- 
coming more  and  more  enfeebled  until  death  ensues.  In  such  extremely 
violent  cases  of  blood-poisoning  we  must  assume  that  the  noxious 
agent  is  bacterial,  that  the  micro-organisms  are  of  exceptional  viru- 
lence, and  that,  in  spite  of  the  resisting  power  of  the  tissues,  they  are 
capable  of  growing  very  rapidly  and  of  elaborating  their  toxic  products 
with  great  rapidity.  The  Streptococcus  pyogenes  is  the  microbe 
usually  thought  to  be  active  in  these  cases. 

Much  less  acute  and  violent  is  the  usual  form  of  septicemia.  When 
a  patient  has  had  for  some  time  a  focus  of  suppuration  which  has  drained 
but  poorly  or  not  at  all,  blood-poisoning,  which  in  this  case  may  be  called 
secondary  septicemia,  is  likely  to  set  in.  The  bacteria  make  their  exit 
from  the  abscess-cavity  through  its  walls,  ruptured  by  tension  or  by 
violence  {e.  g.,  by  the  surgeon's  knife),  and  are  carried  to  the  blood  by 


SEPTICEMIA,   PYEMIA,  AND   SEPTICOPYEMIA.  1 57 

the  lymphatics.  The  long-continued  resorption  of  toxins  from  the 
pent-up  bacteria  causes  a  remarkable  lowering  of  the  resisting  power  of 
the  blood  and  distant  tissues,  so  that  the  bacteria  are  able  easily  to  pro- 
duce their  characteristic  effects  upon  them.  When  the  surgeon  knows 
that  his  drainage  is  imperfect,  he  fears  that  a  daily  afternoon  rise  of  tem- 
perature with  morning  remissions  denotes  a  beginning  septicemia.  The 
morning  temperature  may  recede  to  normal  or  even  to  a  point  below 
normal;  the  evening  temperature  goes  up  to  1030  or  1050  F.  The 
patient  is  bathed  in  a  sour  perspiration  when  the  fever  is  high.  The 
urine  is  correspondingly  high-colored  and  scanty,  and  may  contain 
albumin  and  casts.  The  tongue  becomes  coated  on  the  dorsum,  dry, 
often  cracked,  and  red  at  the  edges.  The  breath  is  often  foul  smelling. 
The  pulse  is  usually  rapid  and  feeble.  The  bowels,  at  first  inclined  to 
be  confined,  are  in  the  later  stages  often  relaxed,  and  the  passages  thin 
and  foul  smelling.  The  mind  for  some  time  is  capable  of  responding 
to  demands  of  the  will,  so  that  when  the  patient  makes  effort  he  can 
concentrate  his  attention  and  answer  questions.  Hebetude  is  early 
observed,  however,  the  patient  often  lying  for  hours  in  a  stupor  unless 
aroused  to  take  nourishment  or  medicines.  These  so-called  "  typhoid  " 
symptoms  deepen,  as  time  passes,  into  a  comatose  state  in  which  the 
passages  are  involuntary,  foods  are  taken  only  when  poured  into  the 
mouth,  the  skin  becomes  dry  and  harsh,  the  pulse  becomes  rapid  and 
feeble,  and  death  is  ushered  in  by  failure  of  the  circulation  and  respira- 
tion— sometimes  due  to  hypostatic  pneumonia.  The  likeness  of  this 
form  of  septicemia  to  typhoid  fever  (which  is  regarded  by  many  as  a 
specific  form  of  intestinal  septicemia)  is  so  marked  that  close  differentia- 
tion is  sometimes  necessary.  Septicemia  of  this  clinical  variety  may  be 
due  to  staphylococci  as  well  as  to  streptococci ;  and  it  may  be  associated 
with,  or  follow,  abscesses  or  erysipelas.  Slow  septicemia  may  go  on  for 
months,  as  every  surgeon  of  experience  can  testify.  The  writer  recalls 
the  case  of  a  man  who  had  had  several  ecrasements  for  tuberculosis  of 
the  knee  and  tubercular  sinuses.  The  suppuration  at  the  site  of  mixed 
infection  continued  in  spite  of  drainage-tubes  passed  through  the  knee 
and  leg  in  all  directions  ;  the  patient's  resisting  power  diminished  instead 
of  growing,  and  the  daily  rise  of  temperature  became  greater  and 
greater.  Marasmus  increased  until  the  patient  was  reduced  to  a  con- 
dition of  debility  pitiable  to  see.  At  this  juncture,  the  formation  of 
metastatic  abscesses  (pyemia)  being  feared,  amputation  through  the 
thigh  was  performed.  The  patient  was  in  one  week  a  changed  man. 
His  temperature  became  normal,  his  sweats  ceased,  his  urine  cleared, 
and,  in  a  word,  he  made  a  rapid  recovery.  As  he  was  a  tall  man  and 
had  lost  much  weight,  he  gained  more  than  fifty  pounds  during  the 
rebound  to  health. 

The  chronicity  or  the  acuteness  of  septicemia  is  due  to  a  variety  of 
circumstances  affecting  the  host  as  well  as  the  microbic  parasite,  and  we 
can  by  no  means  conceive  that  there  is  any  quality  inherent  in  the 
micro-organisms  alone  which  necessarily  brings  about  a  given  course 
of  the  disease.  Recognizing  the  importance  of  removing  or  ameliorating 
all  conditions  that  favor  the  spread  of  the  micro-organism,  it  is  clearly 
all  the  more  our  duty  to  recognize  the  non-essential  character  of  septi- 
cemia in  order  to  combat  it. 


158  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Pyemia  is,  as  we  have  said  before,  not  to  be  sharply  distinguished 
from  septicemia,  since  it  diners  from  it  only  in  the  formation  of  meta- 
static pyogenic  deposits.  The  typical  cases  of  pyemia  are  easily  dis- 
tinguishable clinically  from  septicemia  by  the  finding  of  these  secondary 
abscesses ;  but  when  the  abscesses  are  deep-seated  in  inaccessible  vis- 
cera, their  existence  may  often  be  only  surmised.     The  occurrence  of 

general  intoxication  and  of  true 

^r-^yp  -5?'         septicemia   with    metastatic    ab- 

-__H^_- '___    Vf^       ■      ''"'  '"'■' "": ■■'  scesses  has  often  been  noted,  the 

i.-lf  jj?*i'^~—.a     combination  being  known  clini- 

|//iiv  '    _v  '  • L'j-b      cally  as  septicopyemia. 

ji  (\U      '  W"''  ■  :  Pyemia  differs  clinically  from 

fiffik  tS^W^~J)£~ff~C      septicemia,  as  has  been  said,  in 

^~l"  £f> "  ■'•'        7       -  the  formation  of  metastatic  ab- 

'.  i'-.y    :j  :      '\;   :     '  -,  scesses.     These  abscesses,  when 

l^rl.V';1  l.|  formed  by  the  lodgement  of  in- 

V] :;     I  ■';:■'■     ■  fected  emboli  in  vessels  distant 

1 '  ;  $  _„^.____d  from  the  primary  focus,  arise  in 

i  ■  '      dm'  the    artery    or    vein    itself  in    a 

thrombo-arteritis     or    thrombo- 

/f§p^  phlebitis.        The      inflammation 

fig.  40.— Pyemic  abscess  of  the  kidney :  a,     rapidly   extends   to   the   anemic 

central  dead  tissue  ;  b,  suppurative  zone  ;  c,  zone      tissues  within  the    area    supplied 
of  granulation-tissue  ;  d,  embolus  in  a  branch  of       ,  ,        vessel         Hence     thein- 

the  renal  artery  ;  e,  e,  small  infiltrated  suppura-       DY    rne    vessel.        nence,    me    111 

tive  spots  (Thoma).  crement    of  intoxication    which 

takes  place  when  an  infected 
clot  becomes  suddenly  lodged  in  a  previously  intact  area  is  enormous, 
and  the  system  at  large  responds  clinically  by  a  rise  of  temperature 
almost  invariably  preceded  by  a  violent  chili.  The  chills,  then,  are  a 
very  good  index  of  the  occurrence  of  embolism,  and  serve  to  call  the 
attention  of  the  surgeon  to  the  element  of  pyemia  added  to  the  sep- 
ticemia. 

A  clear  picture  of  typical  pyemia  should  be  fixed  in  our  minds. 
Billroth  has  an  excellent  account  of  a  hypothetical  case  which  he  re- 
lated in  his  lectures.  As  Billroth's  experience  extended  over  part  of 
the  pre-antiseptic  as  well  as  the  antiseptic  age,  he  had  doubtless  seen 
many  such  cases  as  the  one  he  describes.  He  says :  "  Imagine  now 
that  a  wounded  person  has  been  brought  into  the  hospital,  in  whose 
case  you  recognize  a  complicated  fracture  of  the  leg  just  above  the 
ankle,  with  extensive  contusion.  The  injury  has  occurred  by  the 
impact  of  a  very  heavy  falling  body.  You  have  examined  the  wound 
and  found  a  transverse  fracture  of  the  tibia,  and  you  have  decided  for 
conservative  treatment.  Let  us  suppose  that  you  have  applied  a  dress- 
ing such  as  was  used  in  former  times  without  antiseptic  precautions. 
The  patient  feels  well  in  the  beginning,  and  has  but  little  fever  up  to 
about  the  third  or  fourth  day.  Now  the  wound  begins  to  be  more 
strongly  inflamed,  secretes  relatively  little  pus  ;  the  skin  in  the  neigh- 
borhood becomes  edematous  and  red,  the  patient's  fever  increases 
especially  in  the  evening,  the  swelling  in  the  neighborhood  of  the 
wound  increases  and  slowly  extends  farther ;  the  whole  lower  leg  is 
swollen  and  reddened,  the  ankle-joint  very  painful,  and  on  pressure  upon 


SEPTICEMIA,    PYEMIA,    AMD   SEPTICOPYEMIA.  1 59 

the  leg  there  flows  slowly  from  the  wound  a  thin,  foul-smelling  pus.  The 
swelling  remains  limited  to  the  lower  leg,  there  is  no  involvement  of  the 
sensorium,  no  sign  of  intense  acute  septicemia ;  the  patient  is  extremely 
sensitive  at  every  dressing,  peevish  and  disheartened.  A  remittent  con- 
tinuous fever  has  established  itself,  with  tolerably  high  evening  temper- 
ature and  increased  pulse-frequency.  The  pulse  is  full  and  tense,  the 
appetite  is  quite  lost,  the  tongue  is  heavily  coated.  We  find  ourselves 
now  at  about  the  twelfth  day  after  the  injur}-.  Out  of  the  wound  flows 
very  much  pus  from  different  directions.  Somewhat  farther  above  the 
wound  distinct  fluctuation  is  to  be  noted.  With  difficulty  the  abscess- 
cavity  can  indeed  be  emptied  toward  the  wound  by  pressure,  but  the 
outflow  is  very  limited,  and  it  is  consequently  necessary  to  make  an 
incision  at  the  point  named.  This  is  done  and  a  moderate  amount  of 
pus  is  evacuated.  Some  hours  afterward  the  patient  gets  a  severe  chill, 
then  a  dry  burning  fever,  finally  a  very  pronounced  sweat.  The  ap- 
pearance of  the  wound  improves  somewhat,  but  that  does  not  last 
long.  A  new  abscess-cavity  is  noted  farther  back  upon  the  calf  in  the 
neighborhood  of  the  wound.  A  new  chill  occurs,  new  counter-open- 
ings are  necessary,  now  here,  now  there,  in  order  to  provide  a  sufficient 
exit  for  the  pus',  which  is  formed  in  moderate  quantities.  The  left  leg 
being  the  injured  one,  some  morning  the  patient  complains  of  severe 
pain  in  the  right  knee-joint,  which  is  somewhat  swollen  and  painful  upon 
every  movement.  The  nights  are  sleepless,  the  patient  eats  almost  noth- 
ing, drinks  very  much,  is  much  reduced,  becoming  thin  especially  in 
the  face.  The  skin  becomes  slightly  yellow  in  color.  The  chills  are 
repeated,  and  the  patient  now  begins  to  complain  of  pain  in  the  chest. 
He  coughs  a  little,  but  brings  up  only  a  little  sputum.  Upon  examina- 
tion of  the  chest  you  note  a  pleuritic  exudate,  as  yet  moderate,  upon 
one  or  both  sides,  but  the  patient  does  not  complain  very  much  of  i*:. 
So  much  the  more,  however,  does  he  complain  about  the  right  knee, 
which  is  now  very  much  swollen  and  contains  much  fluid.  Since  the 
patient  sweats  a  great  deal,  the  urine  becomes  concentrated  and  occa- 
sionally contains  albumin.  Bed-sores  are  finally  added,  but  the  patient 
scarcely  feels  them.  He  lies  there  in  part  benumbed,  and  mutters  in 
a  low  tone  to  himself.  About  three  weeks  have  now  passed  since  the 
injur}-.  The  wound  is  dry,  the  patient  looks  very  ill,  the  face  and  neck 
are  especially  emaciated,  the  skin  of  a  strongly  icteric  color  and  cool ; 
the  eyes  are  dull,  the  tongue,  trembling  when  put  out,  is  quite  dry,  the 
temperature  is  low,  and  elevated  only  in  the  evening.  The  pulse  is 
very  small  and  frequent,  the  respiration  slow,  and  the  breath  has  a 
characteristic  cadaveric  odor.  Finally  the  patient  becomes  unconscious, 
and  may  remain  in  this  state  perhaps  twenty-four  hours  more  before 
death  occurs." 

Pyemia,  in  the  case  of  wounds  not  treated  antiseptically  (or  asepti- 
cally),  often  takes  the  course  described  by  Billroth.  In  modern  prac- 
tice pyemia  is  quite  infrequently  met  with,  except  when  injuries  are 
much  neglected. 

Even  yet,  however,  it  is  not  uncommon  for  us  to  meet  with  pyemia 
taking  origin  in  the  veins  of  the  face  and  sinuses  of  the  cranium.  The 
facial  veins  which  communicate  with  the  sinuses  of  the  brain  are 
especially  likely  to  become  inflamed  and,  often   undergoing  thrombo- 


i6o 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


phlebitis,  set  emboli  free  to  pass  to  distant  parts  of  the  body.  The 
pyemias  taking  origin  in  the  upper  lip,  involving  the  facial  vein,  are 
likely  to   end  fatally  in   a  few  hours  or  three  or  four  days. 


MG.  41. — Emboli  in  the  branches  of  the  pulmonary  artery,  the  upper  more  closely  adherent 
to  the  wall  and  shrunken  (Thoma). 

The  following  is  a  typical  case  published  by  Hentschel  in  the  Sur- 
gical "Festschrift"  for  Benno  Schmidt  (1896). 

"The  patient,  whose  Czechish  nationality  makes  it  difficult  to  understand  him,  had  some 
days  ago  a  small  furuncle  on  the  upper  lip,  which  was  incised  by  a  physician,  who  observed 
that  a  trace  of  pus  escaped  together  with  some  blood.  Two  days  later  the  upper  lip  and 
face  were  strongly  swollen,  and  the  same  physician  made  four  superficial  incisions  perpen- 
dicularly to  the  lip.  It  is  said  that  neither  pus  nor  blood  escaped.  Late  in  the  evening  of 
the  same  day  the  patient  entered  the  hospital. 

"  His  condition  on  entry  was  as  follows  :  The  young,  powerfully  built  man,  somewhat 
somnolent,  had  a  labored  respiration  and  a  very  small  and  frequent  pulse  ;  the  forehead, 
eyelids,  nose,  and  lips  were  distended  with  well-marked  edema  ;  the  lips  were  very  much 
protruded,  slightly  open,  and  between  them  was  visible  the  equally  swollen  tongue.  The 
answers  of  the  patient  were  given  in  a  chai-acteristic  grunting  tone.  Aside  from  the  symp- 
toms of  acute  inflammation  yet  to  be  described,  the  facies  resembled  in  form  and  expression 
exactly  that  of  a  myxedema  patient.  The  upper  lip  was  so  strongly  swollen  that  the  nares 
were  in  part  closed.  The  lip  was  covered  with  dirty  brownish-red  scabs,  which  were  re- 
moved, disclosing  the  entire  surface  covered  with  numerous  purulent  foci,  large  and  small. 
The  furuncles  observed,  in  all  stages  of  development,  occurred  at  the  border  of  the  lip  and 
extended  far  into  the  mucous  membrane  toward  the  gums.  Furthermore,  some  wounds, 
apparently  produced  by  incisions,  were  found  on  the  upper  lip,  from  which  was  discharged 
a  clear  yellow  serum-like  fluid.  The  disease  of  the  upper  lip  extended  beyond  the  left 
angle  of  the  mouth.  The  left  half  of  the  lower  lip  was  involved  in  quite  the  same  way. 
In  the  region  of  the  left  nasolabial  fold  were  some  blebs  filled  with  a  clear  watery  fluid. 
Upon  the  left  cheek  an  extensive  network  of  veins  shimmered  dark  blue  through  the  skin. 
The  conjunctiva  were  strongly  chemotic  and  reddened.      In  the  connective  tissue  of  the  left 


SEPTICEMIA,   PYEMIA,   A4VD   SEPTICOPYEMIA. 


l6l 


lower  lid  were  to  be  found  a  few  pus-foci.  In  the  lungs  were  to  be  heard  everywhere  sub- 
crepitant  and  large  bronchial  rales.  The  heart's  action  was  stormy,  but  the  pulse  became 
always  weaker  and  more  frequent,  so  that,  even  in  the  night,  the  upper  lip  and  the  diseased 
half  of  the  lower  lip  were  deeply  incised  with  the  knife,  whereupon  tolerably  marked 
bleeding  occurred  from  the  angle  of  the  mouth.  Energetic  irrigation  with  sublimate,  iodo- 
form-gauze  tamponade,  ice,  camphor,  alcoholics,  constituted  the  treatment.  In  spite  of  the 
energetic  application  of  stimulants,  death  occurred  on  the  next  day  at  seven  o'clock  in  the 
morning,  with  symptoms  of  heart-failure.  Post-mortem  examination  was  made  five  hours 
after  death.  The  anterior  facial  vein  was  thrombosed  as  far  as  the  angle  of  the  jaw.  In  the 
internal  jugular  vein  no  thrombi  were  demonstrable.  The  entire  lung  showed  multiple  pin- 
head  to  hazelnut-sized  pus-foci,  with  numerous  small  hemorrhagic  infarcts  and  patches  of 
catarrhal  pneumonia  and  pronounced  edema  in  the  spaces  left  free  ;  the  heart  was  relaxed, 
and  its  musculature  showed  moderate  fatty  infiltration.  In  spite  of  the  most  exact  investi- 
gation, even  with  the  use  of  the  microscope,  no  pyogenic  infection  was  demonstrable  on  the 
valves  and  in  the  myocardium.  Small  abscesses  were  noted  in  the  liver  and  kidneys.  The 
spleen  was  strongly  swollen,  rich  in  blood,  and  soft.  A  very  careful  bacteriological  exam- 
ination showed  everywhere  pure  cultures  of  Staphylococcus  citreus. 

"This  is  the  usual  form  of  pyemia  in  which  the  secondary  lesions  appear  in  the  joints 
and  viscera." 

Nicaise  has  described  a  clinical  variety  of  the  disease  in  which  the 
abscesses  appear  with  special  frequency  in  the  muscles,  myosite  infec= 
tieuse.  E.  Pfister1  describes  a  case  of  the  kind,  which  we  may  briefly 
abstract. 


Fig.  42. — Temperature-chart  in  a  case  of  pyemia  with  muscular  localizations ;  *  indicates  a 
chill.     The  fall  of  temperature  was  frequently  due  to  the  use  of  the  cold  pack. 

Kl.,  twenty-one  years  old,  serving-maid.  History  :  Patient  called  upon  a  physician  on 
May  16  on  account  of  a  slight  lymphadenitis  of  the  axillary  cavity,  for  which  a  small  wound 
of  the  hand  already  cicatrized  was  held  responsible.  On  the  next  day  the  temperature  rose 
to  390  C.  From  May  19  the  patient  improved,  and  treatment  ceased.  She  was  not  alto- 
gether well,  however,  at  any  time.  May  31,  the  physician  was  again  called  on  account  of  a 
prepatellar  bursitis.  At  the  same  time  fever  was  noted  and  a  certain  amount  of  dyspnea,  so 
that  the  patient  was  at  once  taken  to  the  hospital.  On  admission,  June  I,  the  condition  was 
as  follows  :  Well-built,  healthy-looking  girl  ;  anterior  side  of  right  knee  swollen,  skin  red- 
dened and  moderately  tense,  distinct  fluctuation  over  patella,  patellar  region  moderately  sen- 
sitive on  pressure  as  well  as  spontaneously,  no  joint  effusion.  A  diagnosis  of  prepatellar 
bursitis  was  reached,  but  no  incision  was  made  because  purulent  inflammation  was  not 
clearly  apparent.  Treatment  was  limited  to  rest  and  cold  applications.  At  noon  of  the 
next  day  a  pronounced  chill  was  followed  by  a  rise  of  temperature  to  40. 70  C.  and  by  a 
sweat.     After  the  sweat  was  past  the  patient  felt  as  well  as  usual,  but  somewhat  tired.     On 


1  Lang.  Arch.,  Bd.  xlix.,  H.  3. 


11 


1 62 


INTERNATIONAL    TENT-BOOK  OE  SURGERY. 


June  3  the  swollen  bursa  above  the  right  patella  was  punctured,  since  the  chills  were  re- 
peated.  The  puncture  yielded  a  sanguinolent,  tolerably  thin  pus.  An  incision  was  then 
made  for  the  application  of  drainage  and  the  dressings  were  changed  daily.  The  entire  dis- 
ease picture  recalled  pyemia.  On  the  seventh  of  the  month  the  patient  could  see  almost 
nothing  with  the  left  eye,  but  ophthalmoscopic  examination  revealed  nothing.  The  left 
facial  nerve  was  almost  completely  paralyzed.  A  pleuritic  rubbing  was  present;  the  urine 
was  without  albumin.  Every  day  one  or  two  chills  occurred  and  the  respiration  became  fre- 
quent. ( >n  the  eighth  of  the  month  the  cornea  of  the  left  eye  was  diffusely  opalescent ;  the 
bulb  of  the  eye  was  pushed  forward.  On  the  ninth  of  the  month  the  left  arm  and  the  left 
leg  were  almost  completely  paralyzed,  so  that  the  paralytic  phenomena  excited  a  suspicion 
of  brain-abscess.  <  )n  June  IO  the  upper  part  of  the  neck  and  the  region  of  the  ear  began  to 
be  considerably  swollen  and  tender.  The  paralysis  of  leg  and  arm  seemed  somewhat  im- 
proved. On  the  left  heel  there  was  a  fluctuating  pustule  about  the  .size  of  a  franc  piece. 
The  wound  of  incision  at  the  knee  was  dark  colored  and  dry.  On  the  morning  of  June  12 
the  patient  died  with  hyperpyrexia. 

At  the  post-mortem  examination  were  found,  in  the  first  place,  extensive  muscular  sup- 
purations. About  the  sternocleidomastoid  muscle,  about  the  left  upper  arm  and  below  the 
fascia  of  the  triceps,  and  in  the  triceps  itself,  were  found  purulent  infiltrations.  A  myocar- 
dial abscess,  a  subperiosteal  and  a  subcutaneous  pus-collection,  a  slight  pleuritis,  purulent 
gonitis,  and,  besides  these,  a  distinctly  recognizable  metastatic  ophthalmia  and  bursitis  were 
noted.      Streptococci  were  found  in  all  the  lesions. 

These  cases  in  which  a  predilection  seems  to  exist  for  localization  in 
muscular  tissues — a  localization  which  is  thought  to  be  caused  by  ex- 
cessive muscular  activity — are  not  com- 
mon ;  but  localization  in  the  bones  is  of 
frequent  occurrence.  This  form  of  bone- 
inflammation  is  spoken  of  as  acute  osteo- 
myelitis or  infectious  osteomyelitis.  It  is 
specially  treated  in  the  chapter  on  Bones 
and  their  Diseases.  Its  clinical  varieties 
are  great,  but  the  peculiarities  of  the  in- 
flammation, due  entirely  to  the  anatomical 
conditions  supplied  by  bone-structure,  are 
so  characteristic  that  for  a  long  time  it  was 
thought  we  had  to  deal  with  a  special  mi- 
crobe. It  is  now  known  that  any  pyogenic 
bacterium  may  produce  osteomyelitis  just 
as  it  would  produce  a  subcutaneous  ab- 
scess. Localization  of  the  bacteria  circu- 
lating in  the  blood  is  effected  by  injuries 
to  the  bone,  by  the  slowing  of  the  blood- 
current  about  the  epiphyses  in  growing 
children,  by  chilling  of  the  part,  etc.  It  is  unusual  for  pyemia  of  the 
visceral  type  already  described  to  follow  upon  ordinary  osteomyelitis. 
Several  bones,  usually  the  long  bones,  are  simultaneously  or  succes- 
sively affected.  When  several  bones  are  successively  involved,  those 
last  affected  are  often  much  less  seriously  inflamed ;  indeed,  the  only 
manifestation  may  be  a  severe  periostitis  without  necrosis.  Staphylo- 
cocci are  often  the  causative  agent  in  this  form  of  pyemia,  although 
streptococci  are  also  frequently  observed.  The  disease  is  often  so 
violent  in  form  that  death  occurs  in  a  few  days.  In  very  acute  cases 
death  takes  place  before  the  bacteria,  which  have  found  lodgement  in 
the  bones,  have  had  opportunity  to  reproduce  themselves  and  cause 
abscesses.  In  other  words,  the  clinical  signs  may  be  those  of  a  bone- 
inflammation.  Indeed,  in  such  cases  it  is  the  septic  poisoning  which 
causes  death. 


FlG.  43. — Embolic  obstruction 
of  the  trunk  of  the  right  pulmo- 
nary artery  (Thoma). 


SEPTICEMIA,    PYEMIA,    AND   SEPTICOPYEMIA.  163 

On  the  other  hand,  the  local  manifestations  of  osteomyelitis  may  be 
very  chronic,  simulating  tuberculosis,  sarcoma,  or  even  fibroma  and 
osteoma  of  periosteum  or  bone  (Kocher).  These  variations  of  clinical 
form  belong  to  the  chapters  on  Local  Suppuration  and  Osteomyelitis. 

Pyemia  taking  origin  in  thrombophlebitis  may  be  due  to  inflamma- 
tion of  any  vein  sufficiently  large  to  answer  the  anatomical  require- 
ments. But  certain  large  veins  in  different  parts  of  the  body  are 
especially  likely  to  afford  origin  to  pyemia,  and  the  symptomatology 
of  the  disease  as  modified  by  the  local  conditions  may  be  briefly 
considered. 

Pylephlebitis. — Inflammation  of  the  large  branches  of  the  portal  vein 
is,  in  that  commoner  form  of  the  disease  in  which  the  metastatic  de- 
posits are  limited  to  the  portal  circulation,  a  sort  of  local  pyemia. 
Any  suppurative  inflammatory  process  about  one  of  the  large  branches 
of  the  vein  may  set  up  a  pylephlebitis,  the  inflammation  attacking  suc- 
cessively adventitia,  media,  and  intima,  then  bringing  about  a  throm- 
bosis within  the  vein.  The  commoner  causes  of  purulent  pylephle- 
bitis are  operations  within  the  area  supplied  by  the  portal  vein, 
hemorrhoidal  inflammation,  appendicitis,  ulcers  and  carcinomata  of 
the  gastro-intestinal  tract,  localized  purulent  peritonitis,  and  suppura- 
tive retroperitoneal  lymphadenitis.  When  the  coagulum  within  the 
vein  is  softened  and  broken  down,  the  loosened  masses  may  be  swept 
away  in  the  blood-current,  to  be  deposited  in  the  hepatic  branches  of 
the  vein.  Only  exceptionally  are  small  masses  of  infected  coagulum 
carried  through  the  circulatory  system  of  the  liver  to  pass  into  the 
vena  cava  and  cause  abscesses  in  the  tissues  supplied  by  the  systemic 
circulation.  Hence,  as  a  rule,  the  morbid  anatomical  changes  are  for 
the  most  part  found  in  the  liver,  where  abscesses  develop  about  the 
veins  in  which  the  emboli  have  lodged. 

Those  emboli  which  plug  vessels  that  supply  areas  having  good 
anastomoses  do  not  give  rise  to  symptoms  that  enable  us  to  localize 
the  disturbance.  But  in  well-marked  cases  of  the  disease  we  have  not 
only  the  etiology  to  aid  in  diagnosis,  but  also  icterus,  tenderness  over 
the  portal  region,  swelling  of  the  liver  and  spleen,  and  pyrexia  asso- 
ciated with  rigors  (Eichhorst).  Death  usually  occurs  in  pylephlebitis, 
this  form  of  pyemia  being  responsible  for  many  of  the  deaths  in  appen- 
dicitis. 

Pyemia  taking  origin  in  acute  and  chronic  otitis  media — otogenic 
pyemia  (Hessler),  or  otogenic  sinus  phlebitis — has  been  much  studied 
in  the  past  decade,  although  observations  of  the  disease  date  back  to 
the  writings  of  Abercrombie  in  1829  and  of  Lebert  in  1856.  The  close 
anatomical  relationship  between  the  middle  ear  and  the  sigmoid  sinus 
makes  it  easily  possible  for  pyogenic  processes  to  spread  in  a  variety 
of  ways  to  the  great  venous  channel.  Tl;e  thin  walls  of  the  sinus  are 
attacked  from  without,  and  the  series  of  destructive  coagulating  and 
disintegrating  processes  already  described  take  place  until  its  interior 
is  practically  only  an  abscess-cavity.  The  thrombotic  process  may 
then  extend  downward  along  the  course  of  the  jugular  vein,  or  masses 
of  the  coagulum  may  act  as  emboli,  setting  up  metastatic  disease  at 
distant  points.  Purulent  inflammation  of  the  brain  or  its  meninges 
may,  however,  prevent  the  full  development  of  the  pyemia  by  causing 


164  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

death.     A  typical   case  of  otitic  pyemia  is  reported  by  Hessler  in  his 
monograph  on  otogenic  pyemia  (Jena,    1896). 

'•  A  girl  twelve  years  old  had  otorrhea  of  both  cars,  following  scarlet  fever  and  diph- 
theria in  the  seventh  year,  with  loss  of  membrana  tympani,  hammer,  and  anvil,  on  both 
sides.  The  left  ear  ceased  running  after  one  year,  with  total  deafness.  The  right  ear  had 
discharged  continuously,  with  almost  complete  deafness  to  speech.  For  eight  days  before 
admission  a  continuous  infiltration  and  swelling  were  noted  about  the  left  mastoid  process, 
so  that  finally  the  concha  was  lifted  to  a  right  angle  from  the  head.  There  was  no  fluctua- 
tion, and  the  auditory  canal  was  much  swollen.  The  temperature  for  four  days  remained 
above  390  C.  Upon  chiselling  out  the  mastoid  process,  the  bone  externally  appeared  almost 
unchanged,  excepting  that  the  vascular  openings  at  the  ordinary  points  were  very  much 
dilated;  but  in  the  deeper  layers  the  bone  was  softened  in  a  curious  manner.  At  the  pos- 
terior wall  of  the  cavity  of  the  mastoid  process,  which  was  of  the  size  of  a  cherry,  the  dura 
had  to  be  laid  bare,  but  it  was  of  a  normal  bluish  glistening  appearance.  P"or  the  first  eight 
davs  the  patient  felt  perfectly  well,  and  the  wound-healing  was  normal,  when  suddenly  vom- 
iting occurred  with  pyemic  temperature-variations,  but  withoul  <  hills  either  at  the  beginning 
or  later.  There  followed  metastatic  swellings  and  inflammations  in  the  back  of  the  right 
hand,  the  right  shoulder,  and  the  right  hip  region.  At  the  latter  point  a  deep-seated  para- 
articular abscess  had  to  be  incised.  Headache  occurred  only  upon  active  and  passive  move- 
ments. The  sensorium  was  always  entirely  free.  On  the  sixth  day  before  death  vomit- 
ing suddenly  occurred  again  ;  the  abdomen  was  very  markedly  distended,  and  coma  was 
first  noted  twenty-four  hours  before  death.  Upon  post-mortem  examination,  numerous 
metastatic  abscesses  were  found  in  both  lungs,  with  soft  infiltration  of  the  lower  lobes  of  the 
left  lung.  A  broad  embolus  was  found  in  the  spleen,  and  several  smaller,  fresh,  still  hem- 
orrhagic emboli  in  both  kidneys,  side  by  side  with  which  were  several  that  had  passed  more 
or  less  into  a  state  of  suppuration.  The  liver  was  not  changed.  There  were  several  fresh 
metastases  in  the  heart.  The  small  intestine  was  strongly  distended,  as  a  result  of  strangu- 
lation by  axial  rotation  upon  an  abnormally  long  mesentery  close  to  the  cecum.  The  brain 
and  its  membranes  were  absolutely  normal.  In  the  left  transverse  sinus  was  a  thrombus 
which  was  still  firm  at  its  upper  end,  but  at  the  jugular  foramen  had  undergone  suppuration. 
The  membranous  wall  of  the  sinus  was  slightly  discolored  and  softened  upon  the  bony  side 
for  a  space  of  two  centimeters,  especially  at  the  point  where  it  had  been  necessary  to  lay 
bare  the  dura  mater.  The  bony  wall  of  the  sinus  showed,  furthermore,  a  curious  erosion 
and  discoloration.  In  this  case  the  sinus  thrombosis  had  existed  even  before  the  chiselling, 
and  the  operation  had  not  prevented  the  subsequent  infection  and  disintegration  of  the 
thrombus. 

Diagnosis  of  Septicemia  and  Pyemia. — As  a  rule,  septicemia 
and  pyemia  are  brought  to  mind  by  observing  the  positive  symptoms 
already  described.  Continued  fever  in  a  case  of  suppuration,  elevations 
of  temperature  either  in  the  afternoon  or  at  somewhat  irregular  intervals, 
suggest  the  beginning  of  septicemia.  In  pyemia  frequent  chills  are 
noted  on  the  temperature-chart.  In  addition  to  those  characteristics 
already  described,  we  must  consider  the  following  points : 

When  septicemia  comes  on  within  a  comparatively  short  time  after  a 
wound  has  been  inflicted,  the  local  evidences  of  injury  may  have  almost 
or  quite  disappeared.  The  surgeon  should  be  extremely  loath  to  con- 
sider a  case  of  sepsis  as  cryptogenetic  or  spontaneous  (Leube).  Every 
effort  should  be  made  to  discover  the  infection  atrium  by  a  careful  search 
over  the  surface  of  the  body  for  evidences  of  injury  or  its  resultant 
inflammation.  The  natural  orifices  of  the  body  are  then  to  be  examined, 
especially  the  fauces,  the  nose,  and  the  ears.  The  term  cryptogenetic  is 
only  to  be  used  as  a  term  of  clinical  convenience  to  indicate  our  inability 
to  find  the  entrance  point  of  the  microbes. 

Neglected  wounds  giving  rise  to  sepsis  often  show  marked  signs  of 
imperfect  drainage,  exuberant  granulation,  and  cellulitis.  In  the  later 
stages  of  sepsis,  the  injured  tissues  show  almost  no  tendency  to  regen- 
erate, and  the  granulations  have  a  membranous  covering  of  dirty  gray 
material. 


SEPTICEMIA,   PYEMIA,   AND   SEPTICOPYEMIA.  1 65 

The  distribution  of  pyogenic  bacteria  to  the  general  circulation  by 
way  of  the  lymphatic  system  is  proclaimed  by  the  occurrence  of  lymph- 
angitis and  by  temporary  hyperplasia  or  even  inflammation  of  the 
regional  lymphatic  glands. 

When  pyemia  takes  origin  in  thrombophlebitis  of  veins  accessible  to 
direct  or  indirect  clinical  investigation,  symptoms  corresponding  to  the 
obstruction  of  the  blood-vessel  involved  will  be  noted.  For  example,  in 
cases  of  thrombophlebitis  of  the  cavernous  sinus  the  eye  bulges  from 
the  orbit  and  the  lids  are  much  swollen. 

Local  symptoms  of  metastasis  are  more  frequent  in  pyemia,  of  course, 
since  the  secondary  foci  are  susceptible  of  diagnosis  if  they  are  super- 
ficial or  if,  even  when  located  in  deep  structures,  they  interfere  with 
recognizable  functions.  Joint-  and  bone-inflammations,  pleurisy,  endo- 
carditis, nephritis,  etc.,  are  recognizable  with  comparative  ease  when  the 
lesions  are  well  marked.  But  it  must  be  remembered  that  many  second- 
ary points  of  pyemic  inflammation  must  escape  detection,  since  they  may 
remain  small  and  may  not  interfere  seriously  with  any  very  marked 
function.     This  is  especially  true  of  emboli  lodging  in  the  lungs. 

The  secondary  foci  should  be  studied  by  cultural  methods  to  deter- 
mine, if  possible,  whether  the  bacteria  are  of  the  same  species  as  those 
found  in  the  primary  lesion. 

Enlargement  of  the  spleen  is  common  to  all  forms  of  sepsis,  and  that 
organ  should  always  be  interrogated  by  palpation  rather  than  by  per- 
cussion. 

The  blood  in  sepsis  and  pyemia  has  been  studied  frequently.  Leuko- 
cytosis is  present,  the  leukocytes  being  chiefly  polynuclear,  with  neutro- 
phile  granulations.  But  the  diagnostic  value  of  leukocytosis  is  com- 
paratively small,  since  an  unimportant  focus  of  suppuration  anywhere 
in  the  body,  even  though  entirely  unassociated  with  the  disease,  may 
give  origin  to  it.  Nucleated  erythrocytes  are  sometimes  found  in  pro- 
found leukocytosis. 

The  discovery  of  bacteria  in  the  blood  is  of  importance  in  distinguish- 
ing sepsis.  Canon  insists  that  the  blood  should  be  drawn  from  one  of 
the  arm-veins,  especially  in  post-mortem  work,  since  such  blood  is  much 
more  likely  to  show  the  true  state  of  the  infection.  The  blood  is  with- 
drawn by  means  of  a  sterilized  hypodermic  syringe  under  aseptic  pre- 
cautions, and  cultures  and  cover-slip  preparations  are  made. 

Other  important  and  profound  changes  in  the  composition  of  the  blood 
take  place.  Roscher  tells  us  that  the  number  of  the  red  corpuscles  is 
very  much  reduced,  and  proportionately,  also,  the  amount  of  the  residue 
left  after  evaporation.  To  a  special  degree  the  dry  residue  of  the  serum 
is  reduced.  These  differences  are  less  marked  as  the  disease  progresses. 
The  hemoglobin  is  diminished  and  stands  in  direct  relationship  to  the 
number  of  the  red  corpuscles.  None  of  these  changes,  however,  has 
been  studied  clinically  in  a  sufficient  number  and  variety  of  cases  to  put 
us  as  yet  in  possession  of  reliable  diagnostic  aids. 

Many  attempts  have  been  made  to  utilize  in  a  diagnostic  way  the 
urinary  findings.  The  occurrence  of  the  albumoses  in  the  urine  is  noted 
in  sepsis;  but  this  is  common  to  all  the  infectious  diseases  (Harris). 
Of  course,  toxemia  is  associated  with  sepsis,  and  signs  of  nephritis  are 
always  to  be  noted  in  the  later  stages  of  ptomain-poisoning.     The  fact 


1 66 


INTERNATIONAL    TEXTBOOK  OF  SURGERY. 


that  the  urine  in  many  infectious  diseases  contains  soluble  chemical 
bodies  of  a  toxic  character  lessens  the  value  of  a  gross  study  of  urinary 
toxicity  as  a  diagnostic  aid.  Should  we  be  able  hereafter  by  chemical 
means  to  discover  and  distinguish  the  toxic  bodies  peculiar  to  different 
infections,  we  might  be  able  to  use  in  diagnosis  the  knowledge  acquired. 

The  differential  diagnosis  of  sepsis  involves,  first  of  all,  the  exclu- 
sion of  sapremia.  If  autointoxication  is  excluded  by  causing  the 
excretory  organs  to  perform  their  functions  actively,  toxemia  may  be 
ruled  out  by  a  study  of  the  local  findings.  Careful  disinfection  and 
removal  of  all  putrefying  material  in  the  wound  will  enable  us  to  put 
toxemia  entirely  out  of  diagnostic  consideration. 

Local  suppuration  is  converted  into  septicemia  by  the  transmission 
of  bacteria  to  the  blood  and  by  the  multiplication  of  the  microbes 
there.  If,  then,  the  apparatus  by  which  the  germs  are  carried  to  the 
blood  (regional  lymphatic  system)  is  demonstrably  in  a  state  of  activity, 
and  if  cultures  and  stained  preparations  from  the  blood  show  pyogenic 
organisms  on  several  occasions,  the  diagnosis  of  septicemia  is  assured. 
The  temperature-curve,  the  urinary  findings,  and  the  local  symptoms  in 
the  presence  of  free  drainage  will  usually  be  determinative  even  without 
the  blood-examination. 

Typhoid  fever  and  miliary  tuberculosis  are  often  difficult  of  exclusion. 
Hessler  has  prepared  a  table  in  which  these  diseases  are  distinguished 
from  pyemia  of  otitic  origin.  It  is  quoted  because  it  contains  so  much 
information  in  small  space.  The  diagnostic  points  pertaining  to  the 
otitic  origin  of  pyemia  are  suggestive  for  the  study  of  other  forms  of 
the  disease. 


Symptoms. 


Beginning  : 


Running  from 
the  ear  : 


Chills  : 


Temperature  : 


Sensorium . 


Headache  : 


Otogenic  Pyemia. 

Sudden,  with  severe  head- 
symptoms  —  dizziness, 
vomiting;,  headache. 


Has  always  preceded. 


Frequently  recurring  after 
variable  intervals,  fol- 
lowed by  sweats. 

Highly  variable,  atypical, 
going  above  410  C. ; 
often  subnormal. 


For  the  most  part  not 
influenced  in  typical 
cases ;  disturbances  as 
a  result  of  headache, 
alternating  with  or  fol- 
lowing delirium. 

Severe,  one-sided,  varia- 
ble near  the- ear  and 
occiput.  Increases  with 
pressure  on  the  neck 
(MacEwen). 


Typhoid  Fever. 

Begins  with  progressive 
prodromal  symptoms, 
disorders  of  the  general 
condition,  only  rarely 
(Liebermeister)  with  a 
chill  and  elevation  of 
temperature  to  400  C. 

Accidental  complication, 
occurs  for  the  first  time 
in  the  fourth  or  fifth 
week. 

Rare. 


According  to  Wunderlich 
intermittent,  slowly  ris- 
ing and  falling.  Ab- 
sence of  temperature- 
elevation  rare. 

Is  increasingly  disturbed 
at  the  end  of  the  first 
week  ;  later,  muttering 
combined  with  deliri- 
um. Picking  at  the 
bedclothes. 

Equally  distributed  over 
the  head.without  chang- 
ing. 


Acute  Miliary  and 
Meningeal  Tuber- 
culosis. 

Sudden  aggravation  of  an 
old  bronchial  catarrh, 
with  dull  headache  and 
depression. 


A  complication   of  lung- 
tuberculosis. 


Often  at  beginning  a  sin- 
gle chill,  shiverings  fre- 
quent in  course  of  the 
disease. 

At  the  beginning  contin- 
uous at  a  moderate  ele- 
vation, later  hectic,  at 
last  subnormal,  often 
like  that  of  typhoid. 

Only  slight  delirium;  later, 
sopor  and  coma. 


Dull,   variable,  equal  on 
both  sides. 


SEPTICEMIA,    PYEMIA,   AND   SEPTICOPYEMIA. 


167 


Symptoms. 

/  'ami  ting  : 
1  delirium  : 


Lini^-symp- 
toms  : 


Metastases  : 


Otogenic  Pyemia. 


Typhoid  Fever. 


Frequent,  often  recurring    Rare. 
with  the  other  signs  of 
brain-irritation. 

Frequent,    varying    with    More  bland, 
other  brain-symptoms, 
increasing   in    children 
to  convulsions. 

Rapidly  transitory  .scarce- 
ly to  be  demonstrated, 
varying  between  bron- 
chitis, metastatic  ab- 
scesses with  pleurisy, 
and  pyopneumothorax. 

Especially  frequent  in  the    Not  present 
lungs,  rare  in  the  liver, 
in    all    organs    of    the 
body. 


Usually  bilateral,  bron- 
chitic,  in  posterior  lower 
portions. 


Acute  Miliary  and 
Meningeal  Tuber- 
culosis. 

Frequent,  especially  in 
meningeal  tuberculosis. 

Especially  in  meningeal 
tuberculosis. 


Breathing  disproportion- 
ately rapid,  increased 
to  orthopnea.  Sounds 
normal  or  only  large 
rales. 


Appetite  : 

Good  at  first,  then  absent. 

Tongue  : 

In  mild  cases  not  coated. 

Pulse  : 

Hard,  full,  increased  fre- 

quency   in    chills    and 

fever ;       disproportion- 

ately high  in  sepsis. 

Course : 

Irregular  in  the  intensity 

of  the  phenomena  and 

in  duration. 

Abdomen  : 

Rare  distention, occurring 

after  the  second  week. 

Roseola  : 

Lacking  ;  but  we  find  ele- 

vated red  flecks  not  dis- 

appearing on  pressure. 

Diarrhea  : 

In   severe  cases,    toward 

the    end,  then    watery, 

profuse,  fetid. 

Abdominal 

Frequent       over       lower 

pain  : 

spleen  when  metastases 

are  present. 

Spleen  : 

Almost  without  exception 

enlarged  and  palpable. 

Icterus  : 

Frequent,  in    mild   cases 

not  with  certainty. 

Death  : 

In  coma,  usually  by  em- 

bolism of  lungs. 

Optic     neuri- 

Often   very   clearly  pres- 

tis : 

ent,  rarely  septic  retinal 

hemorrhage. 

Blood-exami- 

Gives, when  positive,  dif- 

nation : 

ferent  kinds  of  micro- 

Slight. 

Dry,  coated,  protruded 
with  tremor. 

Hard  and  full,  later  soft, 
dicrotic,  80-100,  paral- 
lel with  temperature. 

• 

Characteristic  tempera- 
ture-curve over  period 
of  three  to  four  weeks. 

Frequently  distended  in 
the  second  week. 

Characteristic  roseola  in 
second  week,  especially 
in  the  lower  breast  and 
abdominal  region,  not 
sensitive  on  pressure, 
often  elevated. 

Characteristic  pea-soup 
stools. 


Not  present. 


Slight. 

Usually  remains  moist. 

Disproportionately  high  ; 
120-150,  soft  and  small. 

Irregular,  lasting  two  to 
three  weeks. 

Not  especially  distended. 

Lacking. 


Only  in  simultaneous  in- 
testinal tuberculosis. 


Ileocecal  pain  in  the  sec-    Usually  lacking, 
ond  week. 

Constantly   swollen    and    As    a     rule,    moderately 

palpable.  swollen. 

Rare.  Rare. 

In  coma,  with  heart-fail-  In  coma,  or  collapse  with 
ure.  failure  of  lungs  or  brain. 

Not  present.  Not    present,     choroidal 

tubercles  frequently 
demonstrable. 

Only  tvphoid  bacillus.  Frequentlv    tubercle   ba- 

cilli. 


organisms  (streptococci 
and  staphylococci). 


Malaria  is  often  to  be  differentiated  from  pyemia,  since  chills  are 
common  to  both  ;  but  the  careful  study  of  the  blood  will  disclose  the 
malarial  organism  if  it  is  present.  Quinin  is  curative  of  most  cases  of 
paludism,  but  only  slightly  influences  pyemia. 

Acute  malignant  endocarditis  and  acute  articular  rheumatism  are  to 
be  distinguished  by  reference  to  the  positive  findings  in  these  diseases 
laid  down  in  the  text-books  of  internal  medicine. 

The  occurrence  of  metastases  in  pyogenic  disease  is  usually  indicated 
by  chills,  temperature-variations,  and  local  signs  peculiar  to  the  part 
involved.     When   metastases   are   found,   the   diagnosis   of  pyemia  is 


1 68  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

thereby  established.  The  diagnosis  of  pyemia  is  not  complete  until  the 
point  is  discovered  at  which  the  infection  found  its  way  into  the  blood. 
This  is  usually  equivalent  to  the  discovery  of  the  vein  undergoing 
thrombophlebitis. 

Treatment  of  Septicemia  and  Pyemia. — The  greatest  triumph 
of  surgery  in  which  the  present  age  rejoices  is  our  recently  acquired 
ability  to  prevent,  in  the  majority  of  cases  in  which  wounds  are  surgi- 
cally inflicted,  the  infection  of  the  exposed  surfaces.  In  pre-antiseptic 
days,  pus  of  certain  characteristics  was  expected  to  form  in  almost  all 
open  wounds  on  the  third  or  faurth  day,  and  was  called  pus  bonum  et 
laudabile.  It  is  now  the  elaborate  and  painstaking  effort  of  every  sur- 
geon to  prevent  suppuration  by  bringing  to  his  aid  a  well-organized 
corps  of  assistants  provided  with  every  needed  appliance.  To  prevent 
suppuration  in  wounds  is  to  avoid  septicemia  and  pyemia;  so  that  the 
prophylactic  treatment  of  these  morbid  conditions  may  be  summed  up 
in  the  principle  involved  in  aseptic  wound  treatment. 

We  must,  moreover,  not  only  avoid  contamination  by  pus-microbes, 
but  we  must  prevent  the  lowering  of  the  resisting  power  of  the  individual 
by  auto-intoxication.  We  must  see  that  the  patient's  bowels  move  prop- 
erly, that  the  kidneys  are  acting  freely  (as  to  excretion  of  urea),  that  no 
intestinal  putrefaction  is  going  on,  etc. ;  and  in  diseases  in  which  intoxi- 
cations are  present — for  example,  nephritis — we  must  either  counsel 
against  operation  or  redouble  our  efforts  to  prevent  contamination.  It 
has  been  shown  experimentally  that  where  a  preliminary  injection  of 
the  toxins  of  a  certain  bacterium  has  been  made,  the  micro-organism 
will  find  lodgement  in  the  tissues  of  the  body  somewhere,  and  grow 
freely  when  injected  in  numbers  so  small  that  without  this  aid  they 
would  inevitably  perish. 

Not  only  does  the  resisting  power  of  individuals  vary,  but  the  resist- 
ing force  of  every  human  organism  varies  from  time  to  time  within 
wholly  physiological  limits.  The  influence  of  hygienic  causes  apparently 
the  most  trivial  is  often  of  vital  importance.  Thus  it  has  been  experi- 
mentally shown  that  rabbits  may  be  made  to  inhale  many  tubercle 
bacilli  without  visible  damage,  so  long  as  they  are  given  free  access  to 
light  and  air ;  but  if  confined  to  dark  places,  they  quickly  die.  In  dis- 
eases in  which  the  date  of  operation  is  elective,  we  may  defer  the  pro- 
cedure until  the  patient  has  been  put  into  the  highest  physiological 
condition  by  proper  hygienic  and  therapeutic  measures. 

Many  cherish  the  hope  that  methods  of  immunization  may  be  in- 
vented which  will  make  it  possible  for  us  to  protect  our  patients 
absolutely  against  pus-infection  before  the  knife  is  used  at  all. 

Even  after  infection  has  occurred,  we  think  of  aiding,  so  far  as  pos- 
sible, those  forces  which  repel  the  microbic  invasion,  and  destroy  or 
eliminate  the  micro-organisms  from  the  body.  This  direct  treatment 
of  suppuration  and  its  various  modifications  and  consequences  has  been 
the  ideal  of  medical  investigators  from  the  earliest  times.  We  certainly 
know  of  no  drug  which  will  exercise  a  direct  influence  on  this  malady. 
But  since  the  publication  of  Behring's  researches  on  the  diphtheria 
bacillus — following  the  proofs  that  an  anthrax-immunity  could  be  pro- 
duced in  certain  lower  animals — and  since  the  "serum-therapy"  of  this 
disease  has  become  an   every-day  fact,  we  have  allowed  ourselves  to 


SEPTICEMIA,   PYEMIA,  AND  SEPTICOPYEMIA.  1 69 

hope  that  an  immunity  against  staphylomycosis  and  streptomycosis  (as 
the  commonest  forms  of  pyogenic  infection)  might  be  established  in 
the  human  body  by  artificial  means. 

Extensive  studies  in  this  field  have  been  published  by  several 
writers.  Marmorek  of  Paris  has  boldly  recommended  the  serum  of 
animals  immunized  by  a  method  of  his  own  devising.  His  first  effort, 
after  choosing  streptomycosis  as  the  field  of  his  activity,  was  to  find  cult- 
ures of  sufficient  virulence  and  to  maintain  that  virulence.  This  he 
succeeded  in  doing,  according  to  his  statements,  by  passing  ordinarily 
active  cultures  of  streptococci  through  the  bodies  of  experimental  ani- 
mals and  by  growing  the  microbes  upon  a  culture-medium  composed 
of  two  parts  of  human  blood-serum  and  one  part  of  meat  bouillon.  In 
this  way  he  obtained  a  culture  so  "  hypervirulent  "  that,  according  to 
his  experiments,  doses  of  as  small  a  quantity  as  one  one-hundred-mil- 
lionth of  a  cubic  millimeter  were  sufficient  to  kill  a  rabbit.  With  this 
potent  virus  asses,  sheep,  and  horses  were  inoculated  in  increasing  doses 
until  they  became  highly  resistant.  Their  serum  remained  toxic  for 
other  animals  and  for  man  for  four  weeks;  but  when  this  period  had 
elapsed  after  the  last  inoculation,  the  serum  conferred  immunity  upon 
animals  when  injected  under  the  skin. 

Without  further  delay  for  study  and  experiment,  Marmorek  began 
applying  his  serum  to  the  treatment  of  human  streptococcus-infections, 
and  reported  a  series  of  injections  with  what  he  considers  favorable 
results.  Of  15  cases  of  puerperal  infection  treated,  7  with  streptomy- 
cosis were  cured,  3  with  mixed  infection  with  Bacterium  coli  died,  and 
of  5  with  mixed  infection  with  staphylococci,  2  died.  From  this  result 
he  argued  that  mixed  infections  are  not  so  favorably  acted  upon  as  the 
simple  infection  with  the  bacteria,  for  immunity  against  which  the  serum 
was  prepared.  In  a  series  of  411  cases  of  erysipelas,  the  mortality 
declined  from  5.12  per  cent,  to  3.4  per  cent.;  but  to  offset  this  slight 
reduction  of  death-rate  Marmorek  claims  that  the  patients  treated  im- 
proved with  wonderful  rapidity  after  the  administration  of  the  serum, 
and  that  their  sufferings  were  much  ameliorated. 

Many  independent  observers  have  tested  the  serum  with  results 
which  are  not  yet  conclusive.  The  critical  and  experimental  review 
of  Petruschky  of  the  Koch  Institute  in  Berlin  is  based  upon  the  study 
of  material  (serum  and  cultures)  from  Marmorek's  laboratory.  Pet- 
ruschky could  not  confirm  the  statements  made  in  regard  to  the  exces- 
sive virulence  of  the  organisms,  nor  could  he  substantiate  the  reports 
of  the  Parisian  experimenter  in  regard  to  the  efficacy  of  the  serum 
even  in  experimental  animals. 

At  the  present  time,  then,  we  have  no  reliable  antistreptococcic  agent, 
and  Lubarsch  even  decides  that,  while  our  present  knowledge  em- 
braces the  established  fact  that  in  experimental  animals  an  immunity 
to  streptococcus-infection  can  be  readily  obtained,  the  blood-serum 
of  the  immunized  animals  contains  neither  antitoxic  nor  bactericidal 
powers. 

W.  Petersen  of  Heidelberg  has  attacked  the  less  promising  question  of  immunity  to 
staphylomycosis.  Petersen  concludes  that  a  transitory  immunity  to  this  disease  exists  when 
man  has  survived  a  severe  attack  of  staphylomycosis,  and  he  decides  that  when  this  im- 
munity exists  there  are  chemical  substances  in  the  blood-serum  upon  which   depends  the 


170  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

resisting  power  of  the  organism.  But  he  also  recognizes  the  weakness  of  these  bodies  and 
their  evanescenl  character.  His  own  experiments  having  been  interrupted,  he  suggests  that 
a  solution  of  the  practical  question  of  securing  immunity  for  man  may  be  found  in  the  dis- 
covery of  other  methods  of  immunization,  or  that  more  active  sera  maybe  obtained  from 
animals  of  species  different  from  those  upon  which  he  experimented.  It  seems  to  him  more 
likely,  however,  that  tile  active  bodies  in  the  immunized  serum  already  obtained  may  be 
separated   by  precipitation,   and   thus  concentrated   lor  use   in  the  maladies  of  man. 

Acting  on  the  theory  that  the  establishment  of  a  leukocytosis  is  of 
benefit  in  combating  pyogenic  conditions,  it  has  been  proposed  to  bring 
about  this  form  of  activity  among  the  wandering  corpuscles  in  normal 
subcutaneous  tissue  by  the  injection  of  such  irritants  as  oil  of  turpen- 
tine. This  suggestion  has  been  put  into  actual  practice.  The  estab- 
lishment, however,  of  even  aseptic  foci  of  inflammation  does  not  find 
ready  acceptance  among  modern  surgeons. 

The  elimination  of  the  micro-organisms  by  all  proper  means  is  to 
be  encouraged ;  but  the  proposed  plan  of  using  phenacetin  and  other 
violent  diuretics,  as  already  mentioned  above,  does  not  seem  wholly 
rational,  since  these  drugs  have  other,  and  often  dangerous,  qualities. 
The  skin  may  be  made  to  do  its  full  duty  by  the  use  of  ordinary 
hygienic  measures.  The  other  emunctories  should  be  kept  active  by 
the  use  of  those  remedies  which,  while  stimulating  excretion,  do  not 
interfere  with  the  functions  of  vital  organs. 

The  principle  of  elimination  is  involved  in  the  plan  of  "  washing 
the  blood,"  or,  as  it  is  sometimes  called,  hypodermoclysis,  in  which  large 
quantities  (one  to  several  pints)  of  normal  salt  solution  are  introduced 
under  the  skin.  The  fluid  is,  of  course,  readily  absorbed  and  passes 
into  the  blood,  while  a  corresponding  activity  of  the  kidneys  tends  to 
carry  away  the  peccant  material. 

The  antipyretics  are  usually  to  be  avoided  because  they  act  as  car- 
diac depressants  (fever  itself  may  be  of  utility  in  combating  the  infec- 
tion), and  because  the  temperature-curve  gives  important  aid  to  the 
surgeon  in  determining  the  nature  and  severity  of  the  disease.  The 
most  important  medicinal  agent  in  the  active  combat  with  septic  infec- 
tions is,  according  to  Billroth,  alcohol.  It  is  borne  by  these  patients  in 
enormous  doses  and  seems  to  exercise  a  favorable  influence  upon  the 
course  of  the  malady.  It  is  administered  in  the  form  of  wine  (the 
stronger  varieties)  and  the  distilled  liquors,  brandy  and  whiskey.  In 
egg-noggs,  egg-flip,  etc.,  we  have  a  ready  means  of  combining  the 
agents  with  food.  With  peptonized  milk  and  eggs  the  alcohol  may 
be  introduced  in  clysters  when  the  stomach  fails.  Digitalis  is  reserved 
until  the  pulse  weakens  ;  but  strychnin,  pushed  almost  if  not  quite  to 
the  physiological  limit,  now  enjoys  a  wide  and  apparently  well-deserved 
popularity  as  a  tonic  stimulant.  Feeding  is  just  as  important  here  as 
it  is  in  typhoid  fever,  and  it  is  the  attendant's  duty  to  see  that  a  regular 
plan  of  feeding  is  arranged  and  adhered  to.  When  the  patient  can  no 
longer  digest  his  food,  it  must  be  digested  artificially  before  it  is 
administered. 

The  influence  of  elevated  temperature  for  the  good  of  the  patient 
cannot  now  be  definitely  decided  upon.  Yet  there  are  not  wanting 
those  who  maintain  that  many  micro-organisms  do  not  flourish  as  well 
at  the  fever-temperature,  that  the  antibacterial  forces  of  the  body  are 
stimulated   by  the   heat,   that    elimination  of  toxins   and   even   of  the 


SEPTICEMIA,    PYEMIA,   AND   SEPTICOPYEMIA.  \J\ 

bacteria  is  encouraged  by  the  fever,  and  that  the  pyogenic  cocci  have 
a  greater  tendency  to  produce  purely  local  reactions  in  the  presence 
of  pyrexia.  Fever,  then,  is  probably  a  beneficent  condition,  and  is  not 
to  be  combated  per  sc  as  the  inimical  element  of  the  disease. 

The  prophylactic  drainage  of  pyogenic  foci  has  for  its  object  the 
removal  of  the  infectious  matter  from  the  body  under  such  technical 
conditions  that  granulations  can  speedily  line  the  avenue  of  their  dis- 
charge and  place  the  abscess,  so  far  as  further  entrance  of  toxins  or 
microbes  into  the  blood  is  concerned,  practically  outside  the  body. 
The  principle  embodied  in  the  Latin  saw,  ubi  pus,  ibi  evacua,  is  thor- 
oughly incorporated  in  the  teachings  of  modern  surgery.  The  early 
discovery  of  the  abscess  and  its  immediate  drainage  will  prevent  most 
cases  of  septicemia  and  pyemia.  It  may  be  necessary  to  amputate 
limbs,  to  resect  intestines,  to  extirpate  a  kidney  or  otherwise  muti- 
late the  body  in  order  to  substitute  simple  for  complicated  wound- 
relations.  Too  much  hesitation  in  the  performance  of  these  operations 
may  be  the  cause  of  the  patient's  death. 

The  opening  of  secondary  foci  should  be  similarly  attended  to  ;  but, 
unfortunately,  when  the  bacteria  are  already  widely  disseminated 
throughout  the  system  or  localized  in  inaccessible  tissues,  the  course 
of  the  disease  is  only  too  frequently  unchecked.  Knowledge  of  this 
fact  does  not,  however,  excuse  us  from  pursuing  the  pyogenic  enemy 
to  the  last  by  freely  draining  its  foci  of  reproduction  wherever  they  can 
be  reached. 

In  pyemia,  quite  as  much  as  in  the  typical  form  of  septicemia,  it  is 
of  high  importance  to  attack  the  primary  site  of  disease,  especially 
when  symptoms  point  to  the  occurrence  of  suppurative  p/debitis. 
When  internal  foci  of  inflammation  are  inaccessible  we  are,  q{  course, 
powerless ;  but  amputation  is  indicated  when  the  extremities  are  the 
seat  of  an  otherwise  uncontrollable  phlebitis.  Extirpation  of  a  puer- 
peral uterus,  whose  veins  are  plugged  by  septic  thrombi,  is  also  indi- 
cated, and  has  been  frequently  practised. 

Septic  pylephlebitis  due  to  localized  suppurative  peritonitis  is  more 
easily  prevented  than  cured.  Early  removal  of  inflamed  tissues  (if 
their  removal  is  permissible)  and  adequate  drainage  constitute  the  best 
safeguards. 

The  accessible  intracranial  sinuses  have  been,  of  late,  frequently 
opened  and  freed  of  purulent  detritus,  and  many  lives  saved.  The 
technic  of  the  operations  and  their  details  must  be  reserved  for  another 
chapter ;  but  an  abstract  of  one  of  Rushton  Parker's  cases  '  will  illus- 
trate the  principles  followed  in  operating  upon  cases  of  thrombophlebitis. 

A  young  man  twenty-five  years  old  had  suffered  a  rupture  of  the  membrana  tympani 
of  the  left  ear  on  account  of  otitis  media.  He  was  attacked  with  sudden  pain  in  the  ear, 
and  from  the  fourth  to  the  ninth  day  of  his  sickness  he  suffered  from  daily  chills,  vomiting, 
imperfect  sleep,  and  pyemic  temperature.  A  fetid  otbrrhea  was  noted  on  examination, 
without  swelling  of  the  mastoid  region,  but  with  tumefaction  and  tenderness  over  the  upper 
part  of  the  jugular  vein.  Double  optic  neuritis  existed,  more  marked  on  the  right  than  on 
the  left  side.  During  the  next  two  days  four  chills  occurred.  On  the  eleventh  day  of  the 
disease  a  radical  operation  was  undertaken,  a  skin-incision  of  seven  or  eight  inches  long 
being  made  over  the  internal  jugular  vein.  The  vein  was  thrombosed  from  the  base  of  the 
skull  downward  to  its  junction  with  the  facial  vein  ;  the  facial  vein  also  was  thrombosed  for 

1  Hessler,  Die  Otogene  Pycemie. 


1/2  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

a  short  distance.  Both  veins  were  ligated  with  catgut,  cut  through  at  healthy  points,  and 
resected  as  far  as  thrombosed.  The  mastoid  process  was  opened  with  hammer  and  chisel 
and  the  transverse  sinus  laid  bare.  It  was  found  filled  with  green,  stinking,  putrefying 
fluid,  and  contained  the  loose  end  of  the  thrombus  which  plugged  the  jugular  vein.  The 
center  of  this  thrombus  showed  upon  section  purulent  softening.  The  thrombosed  vein  was 
cut  away  one  inch  from  the  bone  and  the  rest  scraped  out  with  a  sharp  spoon.  The  trans- 
verse sinus  was  similarly  scraped  out,  and,  upon  further  probing,  a  hemorrhage  occurred 
which  was  stopped  by  tamponade.  Two  days  later  the  tampon  was  removed  under  narcosis, 
since  pus  had  collected  behind  it.  The  lower  half  of  the  wound  was  sutured,  and  healed 
by  first  intention,  while  the  upper  half  was  tamponed  with  gauze.  In  the  course  of  the  next 
week  the  temperature  rose  several  times  to  390  C,  once  indeed  to  400  C,  but  afterward 
the  patient  seemed  to  improve.  After  sixteen  days  he  left  the  bed.  Optic  neuritis  remained 
on  the  right  side,  but  the  subsequent  atrophy  improved  after  three  months,  when  the  mas- 
toid process  had  cicatrized.     The  suppuration  from  the  ear  had  ceased  long  previously. 


CHAPTER    VII. 
ERYSIPELAS;  HOSPITAL   GANGRENE;   TETANUS. 

ERYSIPELAS. 

Erysipelas  is  one  of  the  group  of  hospital  pests  which  antiseptic 
surgery  has  not  been  able  to  banish  from  hospital  wards.  It  is,  how- 
ever, seen  much  less  often,  and  has  been  steadily  diminishing  in  fre- 
quency in  well-regulated  hospitals.  It  may  be  defined  as  an  acute 
inflammation  of  the  skin,  spreading  along  the  surface,  and  rarely  to  the 
deeper  parts,  with  a  tendency  to  spontaneous  recovery.  It  is  accom- 
panied by  acute  febrile  disturbance,  it  may  involve  mucous  membrane, 
it  may  recur.  The  name  is  derived  from  ip'jfif/oc,  red,  and  -£/./.</., 
skin. 

In  the  eighteenth  century  extensive  epidemics  of  erysipelas  visited  Europe — France  in 
1750  and  Great  Britain  in  1777.  In  the  nineteenth  century  epidemics  are  also  recorded  in 
these  countries  as  well  as  in  America.  The  epidemic  in  New  England  in  1842-43  was  of  a 
most  malignant  type.  It  spread  from  village  to  village  in  a  manner  unknown  at  the  present 
time,  and  was  accompanied  by  those  deep  suppurations  seen  only  in  the  severest  forms  of 
phlegmonous  erysipelas,  not  only  the  subcutaneous  tissue  but  even  the  muscles  being  dis- 
sected away  from  their  surroundings  by  the  burrowing  virus.  Since  that  time,  outside  of 
hospital  wards,  we  hear  little  of  epidemic.-,  of  this  disease. 

Ktiology. — The  cause  of  the  disease  is  the  Streptococcus  erysip- 
elatis.  The  single  cocci  are  from  0.3  fi  to  0.4/1  in  diameter.  They  grow 
in  serpentine  chains,  the  links  of  the  chains  forming  pairs  of  cocci,  as 
in  most  forms  of  streptococci.  The  question  of  the  identity  of  this 
organism  with  the  Streptococcus  pyogenes  is  still  in  dispute.  The 
weight  of  authority  at  the  present  time  is  in  favor  of  the  identity  of 
these  organisms.     (See  Chapter  I.) 

The  cocci  are  found  in  the  capillary  lymphatics  of  the  skin  and  in 
the  lymph-spaces  chiefly  (Fig.  44),  but  they  are  sometimes  seen  in  the 
capillary  blood-vessels  and  in  the  small  veins  also.  They  may  be 
found  even  beyond  the  lines  of  the  inflammation  in  parts  as  yet  un- 
changed. Near  the  red  border  the  growth  of  organisms  is  most 
active.  The  lymphatics  are  so  crowded  with  them  that  the  leuko- 
cytes are  hard  to  find.  Chains  of  cocci  may  be  seen  at  this  point  in 
the  adjacent  connective  tissue.  The  cocci  are  not  found  in  the  leuko- 
cytes in  the  lymphatics,  but  may  be  seen  in  the  protoplasm  of  cells  in 
the  tissues.  Nearer  the  center  of  the  infected  area  the  cocci  have 
already  disappeared.  They  are  found  in  small  numbers  only  in  the 
vesicles.  They  do  not  spread  freely  through  the  circulation,  though 
they  may  be  found  occasionally  at  a  distance  from  the  point  of  inflam- 
mation. The  constitutional  disturbance  is  therefore  due  largely  to 
the  presence  of  their  toxic  products.  Though  the  appearance  of  the 
disease  at  distant  points  from  the  seat  of  entrance  is  proof  positive 

17o 


174  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

that  the  organism  may  be  transmitted  from  one  part  of  the  body  to 
another,  yet  the  most  frequent  point  of  entrance  is  through  the  wound. 
This  may  be  an  operation-wound  or  some  abrasion  or  minute  wound 
so  small  as  easily  to  escape  notice.  It  is  also  possible  that  the  organ- 
ism may  gain  an  entrance  through  the  lungs  or  digestive  tract,  and  an 


r      ' 


Fig.  44. — A  small  vessel  near  seat  of  inflammation,  showing  perivascular  lymphatic  crowded 
with  streptococci.     A,  lumen  ;   B,  media  ;    (.'.streptococci. 

intravascular  infection  may  thus  be  produced.  The  healthy  uninjured 
skin  undoubtedly  offers  a  sure  protection  against  infection  through 
that  organ. 

Erysipelas  is  a  highly  contagious  disease.  \  It  has  been  spread  by 
vaccination  with  unclean  technic,  and  epidemics  have  thus  been  pro- 
duced. Attention  was  first  called  to  the  close  relationship  of  erysip- 
elas and  puerperal  fever  by  O.  W.  Holmes.  An  excellent  illustration 
of  this  was  given  in  a  certain  hospital  when  an  attempt  was  made  to 
break  up  an  epidemic  of  puerperal  fever.  The  puerperal  ward  was 
converted  into  a  skin  clinic,  in  which  erysipelas  promptly  appeared. 
Among  the  predisposing  causes,  the  season  of  the  year  was  at  one 
time  supposed  to  be  an  important  agent.  It  is  probable  that  the  early 
spring,  when  the  disease  was  supposed  to  be  more  rife,  was  influential 
only  in  that  the  general  health  of  the  patient  is  less  likely  to  be  vigo- 
rous than  at  other  periods  of  the  year.  Age  is  probably  a  far  more 
important  factor.  One  rarely  hears  of  erysipelas  in  children,  although 
erysipelas  neonatorum  is  still  a  familiar  disease.  Old  people  do  not 
appear  to  be  especially  liable  to  it.  Individuals  broken  down  in  health 
by  long-standing  malignant  disease  or  other  cachectic  disease  are 
undoubtedly  more  susceptible  to  infection  of  this   kind. 

Symptoms. — Constitutional  disturbance  usually  begins  before  the 
local  symptoms  manifest  themselves.  This  is  usually  in  the  form  of 
gastric  disturbance  accompanied  by  pyrexia,  which  symptoms  are 
known  as  prodromal  symptoms.     The  tongue  becomes  heavily  coated ; 


ERYSIPELAS.  1 75 

there  is  a  sense  of  oppression  in  the  epigastrium,  with  malaise,  and 
possibly  at  night  some  delirium.  Some  enlargement  of  the  lymphatic 
glands  may  be  observed  in  the  neighborhood  of  the  wound.  A  day 
or  two  may  pass  before  any  change  occurs  in  the  appearance  of  the 
wound ;  but  occasionally  the  general  symptoms  are  so  slight  as  to 
pass  almost  unnoticed,  and  then  the  earliest  signs  are  seen  in  the 
wound  itself. 

By  far  the  most  characteristic  feature  of  the  disease  is  the  inflam- 
mation of  the  skin.  It  is  recognized  by  an  increased  feeling  of  ten- 
sion in  the  wound,  with  increased  heat,  and  usually  with  an  itching  or 
burning  sensation.  As  exudation  takes  place,  there  are  diffused  red- 
ness and  swelling,  more  or  less  uniform  at  the  center,  but  at  the  edges 
showing  a  zigzag  irregularity  of  outline,  like  the  burned  edges  of  a 
sheet  of  paper.  There  is  a  slight  yellowish  tinge  to  the  part,  and  to 
the  touch  it  feels  more  or  less  indurated.  As  the  inflammation  in- 
creases, minute  vesicles  are  found  in  large  numbers.  Many  of  them 
fairly  run  together  and  form  bullae  filled  with  a  clear  and  slightly  yel- 
lowish serum,  which  subsequently  becomes  turbid  and  at  times  puru- 
lent. The  smaller  vesicles  soon  dry  and  form  yellowish  or  brownish 
scabs  which  furnish  abundant  material  for  desquamation.  This  mate- 
rial, containing  as  it  does  the  organism,  is  undoubtedly  a  prolific 
source  of  contagion. 

The  local  inflammation  shows  a  tendency  to  spread  in  various  di- 
rections. The  outline  continues  to  be  well  marked  and  is  evidently 
due  to  the  invasion  of  new  lymphatic  territories.  The  general  direc- 
tion of  spreading  is,  when  on  the  extremities,  toward  the  trunk  ;  when 
on  the  face,  toward  the  scalp.  It  may  meander  over  extensive  surface, 
and  the  disease  is  then  known  as  wandering  erysipelas  [ambulans  or 
mig  vans). 

At  the  end  of  three  or  four  days  the  local  inflammation  resolves 
and  adjacent  regions  soon  become  affected ;  occasionally  the  inflam- 
mation may  appear  at  a  long  distance  from  the  original  focus  of  infec- 
tion, and  is  then  called  "  metastatic."  It  may  return  again  to  a  part 
after  having  once  left  it.  This  recurring  tendency  is  highly  charac- 
teristic of  the  disease.  Through  all  these  changes  the  inflammation 
continues  to  remain  superficial,  and  suppuration  does  not  take  place. 

The  disease  usually  lasts  from  one  to  two  weeks  and  has  a  decided 
tendency  to  get  well  spontaneously ;  but  even  after  apparent  complete 
recovery  has  taken  place,  there  is  always  danger  of  a  relapse.  Some 
patients  are  subject  to  what  is  called  "habitual  erysipelas,"  coming  on 
at  certain  periods  of  the  year  or  occurring  always  on  certain  parts  of 
the  body.  In  such  cases  there  is  often  an  elephantiasis-like  thickening 
of  the  skin. 

During  the  progress  of  the  inflammation  the  lips  of  the  wound,  if 
it  is  in  the  early  stages  of  healing,  are  swollen,  and  a  thin  seropurulent 
fluid  escapes.  In  open  granulating  wounds  there  is  comparatively 
little  disturbance.  The  disease  sometimes  appears  to  exert  a  stimu- 
lating effect  upon  the  healing  process,  the  wound  healing  more  rapidly 
than  before.  This  is  probably  due  to  the  absence  of  the  virus  in  the 
capillaries  of  the  granulation-tissue,  and  the  extra  blood-supply  which 
they   receive.     The   granulations    are,  however,  occasionally   infected, 


1/6  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

and  then  lose  their  brilliant  color  and  become  dull  and  glazed.  Hem- 
orrhagic and  necrotic  spots  may  be  found  here  and  there.  There  is 
considerable  sloughing  in  fresh  wounds  healing  by  first  intention,  and 
the  healing  process  may  be  badly  broken  up  under  such  circumstances. 
Pus  may  form  and  burrow  freely.  Secondary  hemorrhage  may  occur 
under  these  conditions. 

Pyrexia  is  usually  well  marked.  The  disease  may  be  ushered  in 
by  a  chill  with  a  rapid  rise  of  temperature  which  may  reach  1040  or 
105 °  F.  The  temperature  usually  continues  high,  but  varies  in  a  most 
erratic  manner,  keeping  pace  with  the  local  progress  of  the  disease. 
After  a  prolonged  attack  there  may  be  a  subnormal  temperature  for 
several  days,  probably  due  to  the  feeble  state  of  the  patient. 

Varieties. — Phlegmonous  erysipelas  is  characterized  by  a  spread- 
ing downward  of  the  virus  into  the  subcutaneous  tissue.  The  infection 
is  much  more  extensive  than  in  ordinary  erysipelas,  and  the  local 
symptoms  are  consequently  much  more  marked.  The  fever  continues 
high,  and  is  often  typhoidal  in  character.  It  is  not  long  before  suppu- 
ration takes  place.  Free  incisions  give  vent  to  a  thin  ichor,  in  which 
may  be  found  shreds  of  sloughing  tissue.  Large  sloughs  eventually 
are  discharged,  resembling  masses  of  wet  blotting-paper.  The  pus 
burrows  rapidly,  and  the  skin  for  considerable  distances  is  thus  dis- 
sected off  from  the  subjacent  fasciae.  In  rare  instances,  suppuration 
may  extend  more  deeply  still  and  invade  the  intermuscular  spaces,  but 
this  type,  fortunately,  is  rare.  Even  the  periosteum  and  bones  may 
become  infected,  and  cases  are  recorded  in  which  the  joints  have  been 
involved  and  have  become  disorganized.  In  the  extreme  forms  of  this 
type  large  masses  of  tissue  may  become  gangrenous.  The  approach 
of  gangrene  is  ushered  in  by  a  dusky  discoloration  of  the  skin.  Large 
bullae  form,  filled  with  fluid  having  an  offensive  odor. 

Some  of  the  more  rapidly  spreading  types  of  streptococcus-infec- 
tion, such  as  are  seen  following  infection  of  the  hands,  are  closely 
allied  to  erysipelas,  and  have  been  by  some  authors  grouped  with 
this  disease.  The  close  resemblance  of  the  two  organisms  is  strongly 
suggestive  of  the  similarity  of  the  diseases. 

Facial  erysipelas  has  sometimes  been  called  "  idiopathic  "  erysip- 
elas. Infection  occurs  through  minute  wounds  or  abrasions  near  the 
root  of  the  nose.  Starting  from  the  bridge  of  the  nose,  the  inflamma- 
tion spreads  laterally  across  the  cheeks  toward  the  ear,  rarely  involv- 
ing the  tip  of  the  nose.  It  is  said  to  have  a  preference  for  the  right 
cheek.  Its  outline  is  usually  well  marked.  It  spreads  gradually  over 
one  or  both  cheeks,  and  in  severe  cases  involves  the  entire  face,  the 
ears,  and  eventually  the  scalp ;  less  frequently  it  involves  the  neck.  In 
its  full  development  the  swelling  is  great  and  the  features  are  much 
distorted.  The  eyelids  are  edematous,  and  the  nostrils  are  obstructed 
so  that  the  patient  is  confined  to  mouth-breathing.  There  are  high 
fever  and  a  strong  tendency  to  delirium,  which  is  explained  by  irrita- 
tion of  the  cortex  of  the  brain  rather  than  by  congestion.  This  form 
of  erysipelas  may  become  phlegmonous,  and  orbital  suppuration  may 
occur  with  infection  of  the  eye  itself.  Blindness  is  a  not  infrequent 
result  of  such  complication.  Septic  meningitis  may  also  be  the  out- 
come of  such   severe   types   of  infection   as   this.     But  although  the 


ERYSIPELAS. 


177 


>V 


swelling  of  the  face  may  be  most  formidable  and  the  delirium  of  an 
aggravated  type,  such  cases  may  eventually  terminate  favorably. 

Erysipelas  neonatorum  occurs  through  infection  from  the  granu- 
lating surface  of  the  stump  of  the  umbilical  cord.  The  disease  is 
characterized  by  a  blush  about  the  navel  with  an  extension  of  the 
inflammation  to  the  thighs  and  genitals.  There  is  considerable  fever ; 
gangrene  or  suppuration  may  occur  as  complications.  The  patient 
falls    into    a    collapse    . 


and  succumbs  to  the 
disease  on  the  sixth 
to  the  tenth  clay. 

Erysipelas  is  found 
occasionally  in  the  mu- 
cous membranes.  In 
facial  erysipelas-  there 
may  be  an  extension  to 
the  pharynx  and  again 
back  through  the  Eu- 
stachian tube  to  the  ex- 
ternal auditory  meatus 
and  the  scalp.  It  may 
be  traced  as  far  as  the 
lungs.  Such  combina- 
tions have  been  known 
as  erysipelatous  an- 
gina. If  the  glottis 
should  become  edema- 
tous, as  it  occasionally 
does,  the  result  is 
nearly  always  fatal. 
The  female  genitals 
and  the  rectum  are 
also  occasionally  the 
seat  of  erysipelas. 

Pathological 
Anatomy. — The  prin- 
cipal anatomical  seat  of 
the  disease  is  the  skin. 
The    cells   of  the   epi- 


d 


Fig.  45. — A  section  of  skin  from  scalp  in  a  case  of  erysip- 
elas :  ,1,  epidermic  layer;  vesicle-formation;  b,  cutis  vera, 
leukocvtes  crowding  the  perivascular  lymph-spaces;  c,  sub- 
cutaneous adipose  tissue  with  lines  of  cellular  infiltration  ; 
d,  e,  edematous  connective  tissue  containing  spaces  distended 
by  exudation :  also  perivascular  lymph-spaces  filled  with 
leukocvtes. 


dermic  layer  are  much 
swollen  or  raised  up 
into  vesicles  by  fluid. 
There  is  much  edema 
of  the  softer  structure 
of  the  skin  and  sub- 
cutaneous tissue,  as  shown  by  the  microscope  (Fig.  45).  The  rich 
capillary  network  of  lymphatics  existing  in  the  upper  layers  of  the 
true  skin,  are  crowded  with  leukocytes.  Streptococci  are  found 
near  the  margin  of  the  infected  area,  also  in  the  neighboring 
parts,  in  the  lymphatics,  and  in  the  subcutaneous  tissue.  When  the 
growth  of  streptococci  is  unusually  active,  minute  abscesses  form  and 
12 


178  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

are   often    absorbed   without  giving    any   external    indication    of  their 
presence. 

There  are  no  organisms  found  in  the  blood-vessels,  for  they  are  usually  speedily  destroyed 
there,  probably  by  the  antitoxic  properties  of  the  blood-serum.  The  white  corpuscles  are 
greatly  increased  in  numbers,  and  the  red  blood-disks  assume  a  peculiar  crenated  appearance. 
Endocarditis  involving  the  bicuspid  and  mitral  valves  may  occur,  and  also  pericarditis.  A 
slight  systolic  murmur  is  frequently  heard,  which  disappears  with  the  erysipelas.  The  gas- 
tric disturbance  is  probably  due  to  the  general  sepsis,  as  there  are  no  local  changes  to 
account  for  it.  Ulcerations  of  the  small  intestine  are,  however,  sometimes  seen.  The  brain 
and  membranes  are  somewhat  hyperemic  and  edematous.  Suppurative  meningitis,  which 
is  extremely  rare,  results  from  invasion  from  a  phlegmonous  inflammation  through  the  orbit. 
Cloudy  swelling  of  the  spleen  and  kidneys  and  enlargement  of  the  parotid  gland  are  found. 

Prognosis. — The  prognosis  of  erysipelas  is,  on  the  whole,  favor- 
able. After  a  few  days  of  inflammation  there  is  a  marked  tendency  to 
resolution,  and  this  clinical  fact  should  be  borne  in  mind  in  estimating 
the  value  of  any  remedy.  The  disease  varies  greatly  in  its  severity, 
but  it  may  be  said,  on  the  whole,  that  it  is  less  dangerous  in  itself  than 
through  its  complications. 

The  repair  of  a  wound  is  checked,  and  the  recently  cut  surfaces 
are  exposed  to  a  widespread  sepsis.  There  is  always  danger  in  such 
cases  while  the  infections  last.  A  large  vessel  may  be  opened,  or  a  ' 
fatal  edema  or  infection  of  the  air-passages  may  take  place.  Severe 
erysipelas  of  the  head  or  neck  is  always  a  source  of  anxiety  for  this 
reason,  and  also  from  the  danger  to  the  brain  and  its  membranes. 

Treatment. — This  consists  in  the  use  of  some  local  antiseptic 
application  and  internal  medication.  The  constitutional  treatment  is 
at  the  present  time  supportive.  Purgatives  and  other  depleting  meas- 
ures should  carefully  be  avoided,  as  the  system  needs  strength  to  com- 
bat sepsis.  For  this  reason  alcoholic  stimulants  are  valuable  if  used 
judiciously.  They  are  needed  chiefly  in  the  aged  and  feeble  and  those 
broken  down  by  long-standing  disease.  A  nourishing  and  digestible 
diet  is  of  the  greatest  importance,  and  it  is  probable  that  good  nursing 
has  as  much  to  do  with  the  successful  treatment  of  erysipelas  as  any 
of  the  favorite  methods.  Alcohol  had  better  not  be  given  in  facial 
erysipelas  when  there  is  much  delirium,  although  delirium  does  not 
necessarily  contraindicate  its  use.  Large  doses  of  tincture  of  chlorid 
of  iron  are  supposed  to  have  a  beneficial  effect  upon  the  blood-corpus- 
cle in  this  disease.  It  is  given  in  dram  doses  every  two  hours.  Quinin 
is  also  much  employed.  The  drugs  are  frequently  given  conjointly; 
5  to  10  gr.  (0.33  to  0.66  gm.)  of  quinin  in  combination  with  30  drops 
(2  gm.)  of  the  tincture  of  the  chlorid  of  iron,  given  3  or  4  times  a  day, 
exert  a  powerful  tonic  action  which  is  undoubtedly  beneficial  in  the 
more  chronic  forms  of  erysipelas  or  during  the  later  stages  of  an  acute 
attack.  Antipyretics  have  little  influence  on  the  temperature,  and  are  con- 
traindicated  owing  to  their  depressing  influence  upon  the  heart's  action. 
The  number  of  salves  and  unguents  recommended  for  this  disease 
is  legion.  It  is  probable  that  some  antiseptic  drugs  are  capable  of 
absorption  through  the  skin  and  of  exerting  an  antiseptic  action  upon 
the  organisms.  Among  the  best  of  these  is  carbolic  acid.  This  may 
be  applied  in  vaselin  as  a  vehicle  of  the  strength  of  I  :  IOO  if  a  large 
surface  is  to  be  covered,  and  stronger  when  the  area  is  small.  Care 
should  be  taken  that  it  is  not  absorbed  in  large  doses.     Gutta-percha 


HOSPITAL    GANGRENE.  1 79 

tissue  should  be  applied  over  it  as  a  protection.  On  small  areas  on  the 
face  an  evaporating  lotion  of  carbolic  acid  (consisting  of  \  dram  (2  gm.) 
of  crystallized  carbolic  acid  to  4  ounces  (125  gm.)  each  of  water  and 
alcohol)  may  be  applied  on  a  piece  of  old  linen.  This  lotion  can  be 
arranged  to  alternate  with  some  form  of  antiseptic  ointment.  In  ery- 
sipelas of  the  limbs,  large  antiseptic  poultices  (p.  72)  of  creolin  or  other 
form  of  carbolic  acid  exert  a  moderate  antiseptic  action.  Subcutaneous 
injections  around  the  inflamed  borders  have  not  met  with  sufficient 
success  to  encourage  their  further  use.  In  using  carbolic  acid,  a  care- 
ful watch  should  always  be  kept  upon  the  urine.  An  indication  of  olive 
coloring  should  be  cause  for  omitting  the  drug. 

Isolation  is  important,  as  desquamation  is  always  a  source  of 
danger,  and  it  is  probable  that  autoinfection  may  occur  in  this  way. 
Many  of  the  relapses  are  probably  due  to  a  re-inoculation.  Special 
attention  should  therefore  be  given  by  the  nurse  to  the  care  of  the  skin 
of  the  whole  body.  Frequent  bathing  with  alcohol  and  water,  or  with 
boric-acid  wash,  will  disinfect  the  scaling  epidermis. 

Frequent  change  of  clothing  is  important  for  the  same  reason.  If 
possible,  the  patient  should  have  a  complete  change  of  all  coverings, 
and  should  be  removed  to  another  room  as  a  prophylactic  against 
relapse  during  the  period  of  convalescence. 

Curative  Influence. — During  attacks  of  erysipelas  it  has  long 
been  noticed  that  chronic  diseases  of  the  skin  often  disappeared,  such 
as  tuberculous  nodules,  old  ulcers,  and  sinuses  that  have  obstinately 
resisted  various  modes  of  treatment.  Old  neuralgias  get  well,  and 
even  cancer  has  been  known  to  break  down  and  heal.  The  most 
beneficial  effect  has  been  observed  on  sarcoma.  This  was  first  noticed 
clinically  by  Tillman,  and  now  has  been  employed  for  a  long  time  with 
some  success  by  Coley  and  others.     (See  Sarcoma) 

HOSPITAL  GANGRENE. 

This  disease  has  disappeared,  and  is  unknown  to  the  present  gener- 
ation of  surgeons  in  civilized  countries.  It  is,  however,  highly  prob- 
able that  during  war  and  famine  it  will  reappear,  and  that  it  prob- 
ably exists,  perhaps  unrecognized,  in  some  countries  where  antiseptic 
methods  are  still  unknown.  It  is  desirable,  therefore,  that  one  who 
has  seen  many  severe  epidemics  should  record  his  experience,  as  there 
are  not  a  great  many  surgeons  at  present  living  who  are  able  to  do 
this. 

Hospital  gangrene  is  a  contagious  traumatic  disease,  characterized 
by  a  diphtheritic  wound-inflammation  produced  by  poison,  the  precise 
nature  of  which  is  not  yet  fully  understood  (probably  a  streptococcus), 
and  usually  accompanied  by  more  or  less  profound  septic  fever.  The 
conditions  favoring  an  epidemic  of  this  disease  are  those  which  prevail 
during  war  time,  when  patients  are  crowded  into  hospitals  with  lack 
of  proper  means  of  treatment.  The  disease  ran  rife  in  the  Crimean 
War,  and  also  in  the  American  Civil  War.  The  conditions  prevailing 
in  the  Confederate  prison  at  Andersonville,  South  Carolina,  furnish 
probably  the  most  typical  modern  example  of  those  conditions  favor- 
able for  the  development  of  such  an  epidemic. 


l8o  INTERNATIONAL    TEXT- BO  OK  OF  SURGERY. 

The  ground  covered  by  the  prison  was  about  15  acres  in  extent,  but  the  space  taken  up 
by  the  various  walls  and  the  "dead-line"  reduced  the  space  to  about  12  acres.  This 
ground,  which  sloped  toward  the  center  on  either  side,  was  divided  into  halves  by  a  small 
muddy  brook  which  was  defiled  by  the  refuse  and  sewage  of  the  prison.  A  morass  of 
human  excrement  lined  the  banks  of  the  stream.  There  was  no  protection  to  the  pris- 
oners except  caves  built  by  them.  The  greatest  number  of  men  accumulated  at  any  one 
time  is  said  to  have  been  35,000.  In  the  month  of  August,  1864,  there  were  31,678  pris- 
oners in  the  stockade,  and  the  number  of  deaths  from  all  causes  in  that  month  amounted  to 
2993.  During  the  months  of  July,  August,  and  September,  1864,  there  were  208  deaths 
from  hospital  gangrene  in  Ward  No.  5  of  the  Andersonville  Hospital.  It  is  probable  that 
there  were  a  large  number  of  deaths  from  gangrene  following  bites  from  insects  or  superven- 
ing on  ulceration  from  scurvy,  etc.1 

No  bacteriological  reports  have  been  made  of  the  virus  of  this  disease,  and  no  suitable 
opportunity  has  offered  since  the  advent  of  bacteriology.  It  seems  highly  probable  from 
the  mode  of  action  of  the  virus,  and  from  such  imperfect  histological  reports  as  have  been 
received,  that  the  organism  is  a  streptococcus,  and  possibly  an  organism  which,  by  frequent 
culture  under  certain  conditions  through  several  generations,  is  able  to  produce  the  patho- 
logical phenomena  of  hospital  gangrene.  It  may  be  for  some  such  reason  as  this  that  we 
do  not  see  isolated  cases,  as  in  all  other  traumatic  infective  disease.  The  period  of  incuba- 
tion is  uncertain,  varying  from  twenty-four  hours  to  three  days. 

The  principal  forms  are  the  ulcerating,  the  pulpy,  and  the  diphthe- 
ritic— names  given  to  indicate  the  appearance  of  the  surface  of  the 
wound.  The  local  constitutional  symptoms  are  far  more  pronounced 
in  the  pulpy  form.  This  variety  includes  all  the  graver  cases  with 
extensive  and  deep-seated  loss  of  tissue. 

One  of  the  earliest  symptoms  observed  in  a  wound,  indicating  the 
approach  of  the  disease,  is  a  change  in  the  color  of  the  granulations. 
In  the  era  when  epidemics  of  hospital  gangrene  flourished,  dressers 
were  warned  to  watch  carefully  for  the  "  grayish  look  "  of  the  granu- 
lating surface.  If  this  appearance  became  more  marked,  it  was  evi- 
dent that  the  superficial  layer  of  the  granulation-tissue  had  become 
necrosed,  and  that  a  "  rind  "  or  "  membrane  "  had  formed,  giving  the 
surface  a  diphtheritic  look.  This  is  known  as  the  diphtheritic  form. 
The  secretion  of  the  wound  is  at  first  diminished,  and  later  it  is  increased 
and  becomes  more  liquid  than  usual,  quickly  saturating  the  dressings. 
The  edges  of  the  wound  are  somewhat  inflamed  and  thickened  and 
indurated.  As  the  rind  separates,  sloughs  of  considerable  size  are 
revealed.  The  wound  assumes  a  crater-like  appearance,  and  the  edges 
of  the  wound  appear  as  if  gnawed  by  some  rodent.  When  the  process 
is  arrested  by  treatment,  the  sloughs  are  cast  off,  healthy  granulations 
appear,  the  congested  edges  of  the  wound  resume  their  natural  thick- 
ness and  color,  and  the  cicatrizing  process  is  resumed. 

Ulcerating  Form. — Here  the  formation  of  a  rind  does  not  occur. 
The  granulations  have  an  unhealthy  appearance,  are  paler  than  usual, 
and  lose  their  plump,  exuberant  character.  On  closer  inspection, 
minute  extravasations  or  exudations  are  seen,  and  when  these  points 
break  down,  small  cup-shaped  ulcerations  appear  on  the  surface  of  the 
granulations.  The  edges  of  the  wound  begin  to  recede,  and  the 
wound  becomes  larger.  Sometimes  there  is  only  a  tendency  of  the 
wound  to  enlarge  without  any  marked  organic  changes — a  condition 
analogous  to  ulceration.  At  other  times,  the  wound  gradually  be- 
comes discolored,  and  the  discharge  is  thin  and  streaked  with  blood 
and  has  a  foul  odor  (ichor).  The  interior  of  the  wound  has  finally 
a  dirty-greenish    hue.       The   edges   of  the   skin  are   frequently  quite 

1  Warren's  "Surgical  Pathology." 


Plate  6. 


Ulcerating  hospital  gangrene. 


HOSPITAL    GAXGRENE.  l8l 

unchanged  in  appearance,  and  one  is  often  surprised  to  find  them 
deeply  undermined  with  gangrenous  pockets. 

The  progress  of  the  disease  is  not  rapid,  and  the  breaking  down 
and  enlargement  of  the  wound  and  the  formation  of  sinuses  burrowing 
in  different  directions  may  be  an  affair  of  several  weeks.  In  this  way 
an  amputation-stump  may  become  fairly  riddled  with  pockets  and 
sinuses  extending  up  between  the  muscles  or  beneath  a  fascia.  The 
different  phases  of  phagedena  are  well  portrayed  by  this  type  of  gan- 
grene. There  is  not  much  constitutional  disturbance  at  first,  but  the 
temperature  shows  marked  fluctuations  corresponding  with  the  local 
spread  of  the  infection.  In  a  prolonged  case  of  several  weeks  there  is 
a  corresponding  amount  of  septic  fever,  which,  although  it  does  not 
develop  into  a  true  septicemia,  tells  more  or  less  severely  upon  the 
patient  and  causes  emaciation  and  prostration. 

The  pulpy  form  is  the  most  acute  and  grave  type  of  the  disease. 
The  local  reaction  is  very  pronounced,  and  it  is  evident  from  the  first 
that  a  most  virulent  infection  has  occurred.  The  integuments  of  the 
wound  are  swollen  and  tender,  and  a  thin  gleet}'  discharge  oozes  from 
between  its  lips.  The  inner  surface  of  the  wound  becomes  edematous 
and  sphacelated,  and  the  tissues  are  extravasated  with  numerous  small 
effusions  of  blood.  The  surface  is  soon  changed  to  a  dirty-gray  or 
greenish  mass  of  putrefying  tissue.  The  secretion  from  the  wound 
becomes  enormous,  and  has  a  characteristic  fetid  odor.  The  edges  of 
the  wound  become. everted,  and  the  spongy  mass  of  putrefying  tissue 
wells  up  between  them.  The  edges  of  the  white  skin  marked  with  blue 
veins  are  a  deep  red  and  extremely  sensitive.  These  changes  take  place 
very  rapidly,  and  a  wound  may  increase  to  four  times  its  size  in  from 
twenty-four  to  forty-eight  hours.  In  the  meantime,  the  system  begins 
to  sympathize,  and  true  septicemia  may  be  developed,  which  may 
carry  the  patient  off.  As  the  infection  advances,  no  tissues  are  spared : 
the  muscles  are  laid  bare  and  the  nerves  are  dissected.  The  fasciae  are 
more  resistant.  Articulations  may  be  laid  open,  and  even  the  bones 
may  not  escape  necrosis.  The  great  swelling  which  takes  place  is 
often  deceptive  as  to  the  amount  of  tissue  which  has  been  lost.  This 
is  obvious  after  the  sloughs  have  separated  and  the  coverings  of  the 
wound  contract.  Although  septicemic,  the  patients  are  fully  alive  to 
the-  sensitiveness  of  the  wound,  which  at  times  appears  to  be  hyperes- 
thetic.  The  pain  attending  the  dressing  of  wounds  in  some  cases  is  so 
great  that  few  men  possess  the  fortitude  to  go  through  the  ordeal. 
Secondary  hemorrhage  is  a  not  infrequent  complication  of  this  type 
of  gangrene.  Ligature  of  the  artery  at  the  point  of  election  may 
be  followed  by  gangrene  of  the  new  wound  and  a  later  hemorrhage 
from  this  point.  Erysipelas  is  also  an  occasional  complication  of  the 
disease. 

Diagnosis. — There  is  occasionally  some  difficult}-  in  recognizing 
the  disease  in  its  early  stages.  Mechanical  or  chemical  irritation  may 
produce  changes  in  the  appearance  of  the  granulation.  This  may 
result  from  irritating  dressings  or  from  the  presence  of  a  foreign  body 
in  the  recesses  of  the  wound  or  sinus.  In  aged  patients  a  superficial 
slough  will  often  form  on  the  surface  of  a  rind  caused  by  the  coagula- 
tion of  the   slowlv   secreted   exudation.     Occasionallv   bed-sores  will 


I  82  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

counterfeit  closely -the  appearance  of  this  disease,  both  in  the  slough- 
ing character  of  its  surface  and  in  the  rapidity  with  which  it  grows. 

Prognosis. — The  prognosis  of  the  disease  is  very  variable.  Iso- 
lated cases  are  usually  of  a  subacute  or  chronic  type ;  it  is  only  in  epi- 
demics under  unusually  unfavorable  conditions  that  the  malignant 
types  of  the  disease  are  observed.  In  the  "  Surgical  History  of  the 
War  of  the  Rebellion,"  the  number  of  cases  of  hospital  gangrene  re- 
corded was  2642.  Of  these  cases,  1142  were  fatal,  making  a  mortality 
of  45.6  per  cent.  In  one  of  the  more  recent  epidemics  which  occurred 
in  the  barracks  at  Berlin,  the  mortality  was  only  6  per  cent. 

Treatment. — In  order  that  local  treatment  may  be  of  any  avail, 
the  agent  employed  should  be  brought  directly  in  contact  with  the 
freshly  diseased  tissue.  The  dead  tissue  on  the  surface  must  then  be 
cut  away,  and  all  sinuses  must  be  relentlessly  laid  open,  so  that  every 
particle  of  infected  tissue  may  be  subjected  to  the  action  of  the  anti- 
septic drug.  The  actual  cautery  has  always  been  a  popular  mode  of 
treatment.  It  is  said  to  be  less  painful  than  applications  of  perchlorid 
of  iron.  Cold  applications  applied  subsequently  relieve  the  pain.  An 
antiseptic  poultice  (p.  72)  alternating  with  an  antiseptic  bath  would  favor 
the  separation  of  the  sloughs  and  prevent  relapse.  Nitric  acid  in  full 
strength  was  used  by  Southern  surgeons  during  the  Civil  War.  "  The 
acid  should  not  merely  coagulate  and  alter  completely  the  gangrenous 
matters,  but  also  come  in  contact  with  the  sound  parts  "  (Jones).  For 
such  severe  measures  the  patient  should  be  placed  under  the  influence 
of  an  anesthetic. 

Keen  used  acid  nitrate  of  mercury,  preferring  it  to  nitric  acid,  as  it  caused  less  pain  and 
saved  time  by  enabling  the  surgeon  to  dispense  with  an  anesthetic.  The  slough  also  sepa- 
rated more  quickly.  Goldsmith  advocated  strongly  the  application  of  pure  or  fuming 
bromin.  It  spreads  readily  in  all  directions,  and  its  action  is  almost  instantaneous.  In 
milder  cases  an  acid  wash  containing  hydrochloric  acid  was  used  for  many  years  at  the 
Massachusetts  General  Hospital.      It  can  be  applied  on  gauze. 

R   Potass,  chlor.,  5SS  (i6gm.)  ; 

Acid,  hydrochlor.,  gj  (3.75  c.c. ). 
Misce  et  adde 

Aquce,  ovuJ  (236c.c). 

Most  of  these  remedies  would  be  abandoned  at  the  present  time 
for  modern  antiseptics.  It  would  be  necessary,  however,  to  curet  and 
cut  away  all  gangrenous  tissue  with  the  same  care  as  was  employed 
formerly.  Hydrogen  peroxid  would  be  eminently  useful  in  aiding  in 
the  destruction  of  the  dead  organic  matter.  It  could  be  followed  by 
an  application  of  carbolic  acid,  1  :  20  or  1  :  40.  All  recesses  of  the 
wound  should  then  be  stuffed  with  iodoform  gauze.  An  amputation 
for  hospital  gangrene  of  a  stump  was  successfully  performed  by  a 
German  surgeon  in  1870.  The  antiseptic  agent  used  was  "phenyl 
water." 

All  cases  should  be  immediately  isolated,  and  the  ward  in  which 
the  case  occurred  should  be  thoroughly  cleansed  and  disinfected.  A 
chronic  case  which  has  obstinately  resisted  local  treatment  will  often 
improve  rapidly  after  a  complete  change  of  room,  of  bedding,  and  of 
clothing;. 


TETANUS.  183 

TETANUS. 
The  name  is  derived  from  veivecv,  to  stretch.  Tetanus  is  an  in- 
fectious disease,  traumatic  in  origin,  characterized  by  painful  tonic 
contraction  of  the  muscles,  beginning  with  those  of  the  jaw  or  the 
neck,  and  affecting  progressively  the  muscles  of  the  trunk  and  limbs. 
It  is  accompanied  by  convulsive  paroxysms  and  an  irritation  or  inflam- 
mation of  the  nerve-centers  in  the  upper  portion  of  the  cord.  It  is  due 
to  the  presence  of  a  bacterial  virus  in  the  blood  and  tissues. 

The  Bacillus  tetani  was  discovered  in  18S5.  It  is  a  long;,  slender  rod,  in  one  end  of 
which  a  spore  forms,  distending  the  cell  into  a  "  drumstick  "  shape  (see  Chapter  I,  Fig.  4). 
It  is  one  of  the  most  marked  types  of  anaerobic  bacteria.  The  organism  is  found  principally 
in  the  tissues  near  the  wound  of  entrance,  but  it  has  not  been  satisfactorily  demonstrated  in 
either  the  blood,  the  internal  organs,  or  the  central  nervous  system.  It  is  assumed  that  the 
organisms  manufacture  at  the  point  of  entrance,  or  that  there  is  introduced  with  them,  an 
extremely  active  poison  which  disseminates  itself  throughout  the  body.  The  relation  of  the 
toxin  to  the  organism  and  to  the  system  in  tetanus  is,  according  to  the  latest  authorities,  not 
yet  clear.1  The  tetanus  bacilli  are  found  in  large  numbers  in  the  soil,  particularly  in  garden 
soil,  in  the  dust  and  sweepings  of  our  streets  and  dwellings,  in  crumbling  masonry,  in  putre- 
fving  fluids,  and  in  manure.  Their  presence  in  these  localities  is,  however,  always  uncer- 
tain. It  often  happens  that  particular  geographical  regions  are  favored  by  its  presence.  It 
is  only  by  experimental  inoculations  that  its  presence  can  definitely  be  established  in  any 
locality.  Owing  to  the  anaerobic  nature  of  the  organism,  the  bacilli  are  unable  to  grow 
upon  small  and  superficial  wounds,  except  in  rare  instances.  Punctured  wounds  lodge  the 
organisms  deep  in  the  tissue,  a  soil  better  fitted  for  their  growth. 

Ktiology. — Among  the  predisposing  causes  of  tetanus  may  be 
mentioned  age.  It  is  peculiarly  fatal  to  children  under  ten  years  of 
age.  The  disease  is  said  to  be  rare  in  later  life.  Meteorological 
changes  have  been  said  to  favor  tetanus.  Certain  changes  of  weather 
after  battles  have  been  repeatedly  noticed  as  preceding  epidemics  of 
tetanus.  In  tropical  countries  the  disease  appears  to  be  much  more 
common.  The  gravity  of  the  wound  does  not  appear  to  have  any 
influence  upon  the  severity  of  the  disease. 

All  cases  of  tetanus  are  traumatic  in  origin — that  is,  it  is  highly 
probable  that  the  poison  is  introduced  through  some  wound,  however 
slight,  whether  of  the  skin  or  mucous  membrane.  The  old  term 
"  idiopathic  tetanus "  had  better  be  abandoned.  The  term  seems, 
however,  to  show  that  many  cases  of  tetanus  do  occur  when  there  is 
no  appreciable  wound.  Cases  of  tetanus  following  simple  fracture 
have  been  reported;  also  infection  through  so  slight  an  injury  as  a 
hang-nail. 

Varieties. — Tetanus  is  divided  into  acute  and  chronic  forms,  the 
former  being  almost  invariably  fatal,  and  cure  often  occurring  in  the 
latter  variety.  Puerperal  tetanus  and  trismus  nascentium  are  varieties 
usually  considered  as  a  group  by  themselves,  but  they  are  in  reality 
not  distinguished  etiologically  from  traumatic  tetanus.  Head-tetanus 
or  tetanus  hydrophobicus  presents  certain  clinical  peculiarities  which 
justify  placing  it  in  a  class  by  itself. 

Acute  tetanus  usually  has  a  period  of  incubation  of  about  one 
week.  The  first  symptom  is  a  stiffness  of  the  muscles  of  the  neck, 
coming  on  in  the  morning  after  a  comfortable  night's  rest.  It  is 
usually  attributed  to  a  cold,  but  during  the  day  the  stiffness  extends 

1  Rose,  in  his  exhaustive  work,  "  Der  Starrkrampf  bei  Menschen,"  1897,  pronounces  it 
an  unsolved  riddle. 


184  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

to  the  muscles  of  the  jaw,  making  it  difficult  for  the  patient  to  open 
his  mouth.  There  is  as  yet  no  discomfort,  but  the  contractions  soon 
become  painful,  and  owing  to  their  power  and  frequency  it  becomes 
difficult  even  to  swallow  liquids.  The  masseters  are  now  felt  in  a 
state  of  rigid  contraction  as  hard  as  iron,  and  with  well-marked  bor- 
ders. The  muscles  of  the  back  of  the  neck  are  next  involved,  and  the 
head  is  thrown  backward  by  their  contraction.  Before  the  close  of 
the  day  all  the  muscles  of  the  back  are  affected,  producing  opisthot- 
onos. If  the  hand  is  now  passed  down  to  the  abdomen,  the  parietes 
are  felt  as  firm  and  rigid  as  a  metal  plate.  There  is  already  retention 
of  urine,  which  when  drawn  off  with  the  catheter  appears  to  be  abun- 
dant and  of  a  normal  color.  The  muscular  spasm,  at  first  clonic,  be- 
comes now  continuous  or  tonic.  Attempts  to  swallow  cause  pain  and 
distress.  After  a  sleepless  night  the  patient  is  found  the  next  morning 
well  advanced  in  the  stage  of  full  development  of  the  disease.  The 
locking  of  the  jaws  is  as  complete  as  before,  and  nearly  all  the  volun- 
tary muscles  of  the  body  except  those  of  the  upper  extremities  are 
involved.  The  arms  may  also  be  involved,  but  only  to  a  partial  ex- 
tent. The  lower  extremities  are  rigidly  extended.  The  muscles  of 
the  face  are  affected ;  the  eyelids  are  seamed,  the  nostrils  and  the 
mouth  are  puckered  in  a  peculiar  way,  while  its  corners  are  drawn 
back  by  a  contraction  of  the  cheeks.  The  eyes  are  drawn  in  and 
partly  closed,  and  occasionally  there  is  strabismus  (Risus  sardonicus). 
The  patient  is  now  extremely  sensitive  to  disturbance  of  any  kind  ; 
attempts  to  move  him  in  bed,  to  administer  nourishment,  or  to  pass 
the  catheter  bring  on  a  paroxysm  of  convulsive  action  of  the  most 
painful  character.  The  violence  of  muscular  contraction  has  even  been 
sufficient  to  produce  rupture  of  the  muscle. 

Meanwhile  the  patient  lies  as  still  as  possible,  usually  upon  his  side, 
with  his  head  drawn  rigidly  backward  and  with  a  deep  hollow  in  the 
curve  of  the  spine.  His  mind  is  perfectly  clear,  but  the  rigidity  of  the 
muscles  of  the  jaws  and  cheeks  does  not  enable  him  to  articulate 
clearly.  The  spasm  of  the  sphincters  renders  voluntary  evacuations 
of  the  bowels  or  the  bladder  very  difficult. 

During  the  height  of  the  disease — that  is,  on  the  third  or  fourth 
day,  exhaustion  becomes  marked  from  loss  of  nourishment  and  sleep. 
Short  periods  of  sleep  may  be  obtained  by  drugs,  during  which  there 
is  some  relaxation  of  the  muscular  spasm  ;  but  no  complete  remission 
ever  occurs,  and  the  patient  is  soon  startled  out  of  a  disturbed  slumber 
by  renewed  convulsive  movements.  There  is  usually  little  fever ;  the 
temperature-curve  is  in  no  way  characteristic  in  this  disease,  but  as 
death  approaches,  and  even  post  mortem,  there  may  be  hyperpyrexia. 
There  is  occasionally  found  after  each  convulsion  a  tendency  to  free 
perspiration,  which  may  become  quite  a  characteristic  feature  of  the 
case.  It  acts  probably  as  a  means  of  dissipating  the  heat  produced  by 
the  active  and  extensive  innervation  of  the  muscular  fibers. 

In  the  last  stages  of  the  disease  the  mind  continues  clear,  delirium 
is  extremely  rare,  and  the  patient  is  fully  sensible  of  the  agonizing 
spasm  to  which  the  slightest  noise  or  disturbance  in  the  sick-room 
gives  rise.  In  tropical  climates  the  disease  may  run  a  still  more  acute 
course,  death  supervening  a  few  hours  after  the  onset  of  the  attack. 


TETANUS.  185 

In  chronic  tetanus  the  period  of  incubation  is  longer,  the  first 
symptoms  making  their  appearance  during  the  third  week.  The  order 
in  which  the  muscular  system  is  involved  is  the  same  as  in  acute  teta- 
nus, and  the  spasms  may  be  of  great  severity,  but  there  are  periods 
during  which  the  patient  experiences  relief  from  muscular  contrac- 
tions. These  periods  gradually  become  longer,  and  soon  an  entire 
day  may  pass  without  a  relapse.  There  is  great  prostration,  partic- 
ularly when  the  disease  is  prolonged  by  frequent  relapses.  Cases  of 
six  weeks'  and  of  two  months'  duration  are  occasionally  seen.  Yan- 
dell  reports  one  case  in  which  the  duration  of  symptoms  was  two 
hundred  and  forty  days. 

Head=tetanus  or  tetanus  hydrophobicus  occurs  after  injuries  in 
the  region  of  distribution  of  any  of  the  twelve  cranial  nerves  ;  conse- 
quently it  is  chiefly  confined  to  the  head.  It  is  characterized  by  spasm 
of  the  pharyngeal  muscles  and  paralysis  of  the  facial  nerve,  as  well  as 
trismus,  and  occasionally  by  tetanic  contraction  of  the  muscles  of  the 
neck  and  abdomen.  Rose  explains  the  paralysis  of  the  facial  nerve 
by  compression  in  the  petrous  portion  of  the  temporal  bone,  due  to 
swelling  of  the  nerve.  According  to  Bunner,  the  reported  symptom 
of  facial  paralysis  is  due  to  an  error  of  observation. 

Cephalic  tetanus  occurs  usually  after  a  wound  in  the  face,  such  as 
may  result  from  a  blow  from  a  whip-stock  or  the  fist  in  a  street-brawl. 
The  paralysis  of  the  facial  nerve  almost  always  occurs  on  the  same 
side  as  that  in  which  the  injury  is  received.  There  is  usually 
marked  paralysis  of  the  lower  lid  on  that  side.  A  marked  feature 
of  this  form  of  tetanus  is  the  difficulty  in  swallowing,  "which  symp- 
tom has  given  rise  to  the  term  tetanus  hydrophobicus.  This  symptom, 
however,  is  not  always  present.  Head-tetanus  is  not  always  fatal. 
In  a.  collection  of  24  cases  of  head-tetanus,  7  recovered,  and  of 
these  6  were  cases  of  chronic  tetanus. 

Pathological  Anatomy. — There  is  little  change  in  the  appear- 
ance of  the  wound.  Occasionally  there  is  a  slight  blush  about  its 
edges,  and  sometimes  there  are  evidences  of  lymphangitis.  Wounds 
of  the  extremities  are  more  likely  to  be  followed  by  tetanus  than 
wounds  in  other  regions,  probably  because  they  are  exposed  to  punct- 
ured wounds,  the  foreign  body  carrying  in  with  it  dirt  which  may  con- 
tain the  virus.  A  rusty  nail  thrust  into  the  sole  of  the  foot  is  a  not 
infrequent  cause  of  the  disease ;  the  organisms  are  thus  carried  deeply 
into  the  tissues,  and  have  an  opportunity  to  develop  there  undisturbed 
by  oxygen  or  suppuration.  There  is  sufficient  evidence  to  show  that 
the  virus  acts  with  more  or  less  power  chiefly  upon  the  nervous  centers 
of  the  cord  and  medulla,  but  the  data  do  not  yet  seem  to  be  sufficient 
to  establish  the  fact  of  multiple  neuritis  or  irritation  of  the  trunks  or 
branches  of  the  nerves  over  and  above  that  of  other  tissues  to  which 
the  virus  may  be  conveyed.  Evidences  of  inflammation  of  the  brain 
and  meninges  are  wanting,  but  a  number  of  observations  point  to 
inflammation  in  the  upper  portions  of  the  cord. 

Diagnosis. — The  disease  is  not  difficult  to  recognize  in  the  fully- 
developed  stage,  but  in  the  nature  of  the  early  symptoms  there  may 
be  some  doubt.  Stiffness  of  the  jaws  may  be  due  to  inflammatory 
affections   of  the   mouth   or  the  teeth,  or  to   abscess   of  the  cervical 


1 86  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

glands,  and  also  to  rheumatic  affection  of  the  temporomaxillary  artic- 
ulation. Occasionally  a  hysterical  contraction  of  the  muscles  of  the 
jaw  may  occur. 

The  question  of  death  by  tetanus  or  by  strychnin  has  been  raised 
in  medico-legal  cases.  In  strychnin  poisoning  there  is  usually  no  lock- 
jaw ;  there  is  hyperesthesia  of  the  retina,  and  objects  seen  are  colored 
green.  During  a  paroxysm  the  mouth  foams  and  the  teeth  lacerate 
the  tongue.  There  is  also  spasm  of  the  muscle  of  the  limbs  and  trunk. 
The  occurrence  of  muscular  spasm  is  irregular,  and  depends  upon  the 
frequency  and  size  of  the  dose.  Tetany  affects  chiefly  young  per- 
sons, and  consists  in  tonic  spasms  of  various  groups  of  muscles, 
most  frequently  those  of  the  upper  extremities.  The  attacks  are 
short  and  more  or  less  localized,  and  Trousseau's  symptom,  seen  in 
no  other  convulsive  disease,  is  always  present.  This  symptom  con- 
sists in  the  peculiarity  that  pressure  upon  the  nerve-trunk  leading 
to  the  group  of  muscles  affected  always  brings  on  a  characteristic 
attack. 

Hydrophobia  is  said  to  resemble  tetanus  owing  to  the  difficulty  of 
swallowing  in  the  two  diseases.  There  is,  however,  no  convulsion  in 
hydrophobia.  The  hydrophobic  paroxysm  is  due  to  an  inhibition  of 
the  respiratory  nerve-center  and  the  natural  movements  of  distress 
which  this  calls  forth.  The  clinical  pictures  of  the  two  diseases  pre- 
sent striking  contrasts  to  one  who  has  seen  them  both. 

Prognosis. — Acute  tetanus  is  one  of  the  most  fatal  of  diseases. 
In  chronic  tetanus  the  percentage  of  mortality  is  very  much  lower. 
According  to  Hippocrates,  the  patient  dies  on  the  third,  the  fifth,  the 
seventh,  or  the  fourteenth  day ;  if  he  survive  this  period  he  recovers. 
According  to  the  tables  of  the  "  Surgical  History  of  the  War  of  the 
Rebellion,"  of  337  deaths,  287  occurred  during  the  first  week  of  the 
disease ;  and  of  those  occurring  on  the  eighth  day  there  were  but  7 
deaths.  In  Yandell's  415  cases,  there  is  a  marked  falling-off  of  deaths 
on  the  fifth  day,  when  there  were  but  1 1  deaths,  from  which  time  the 
percentage  steadily  diminished.  Rose  states  the  mortality  of  early 
cases  as  91   per  cent.,  and  that  of  late  cases  as  48  per  cent. 

Treatment. — Among  the  internal  remedies  which  have  enjoyed  a 
more  than  usual  reputation  may  be  mentioned  Calabar  bean,  chloral, 
cannabis  Indica,  curare,  amyl  nitrite,  quinin  and  opium.  Yandell 
places  chloroform  at  the  head  of  the  list  in  cases  of  acute  tetanus,  but 
also  makes  the  significant  statement  that  when  tetanus  continues  four- 
teen days  recovery  is  the  rule  and  death  the  exception,  apparently 
independent  of  the  treatment. 

Calabar  bean,  when  given  in  small  doses,  relieves  the  muscular 
contraction.  Poncet  advises  from  1  to  \\  gr.  (0.065  to  0.1  gm.)  of  the 
extract  given  every  four  hours,  or  from  1 5  to  20  drops  (0.92  to  1.25  c.c.) 
of  a  1  per  cent,  solution  may  be  injected  subcutaneously. 

Chloral  seems  to  be  most  efficacious  in  chronic  tetanus ;  it  relieves 
pain  and  prevents  spreading  of  the  muscular  spasm  and  recurrence  of 
the  convulsions.  It  appears  to  act  by  diminishing  the  reflex  excita- 
bility of  the  nerve-centers.  In  large  doses  (from  100  to  200  gr.  (6.5  to 
13  gm.)  a  day)  chloral  will  relieve  muscular  spasm  in  acute  tetanus, 
but  it  does  not  appear  to  have  any  appreciable  effect  upon  the  mor- 


TETANUS.  187 

tality.  Chloroform  may  be  administered  by  inhalation.  Its  action 
is   decidedly  sedative,  but  not  so  enduring  as  that  of  chloral. 

Opium  does  not  appear  to  enjoy  the  popularity  of  chloral  and 
chloroform.  Large  doses  are  required,  and  the  digestive  disturbance 
caused  by  the  drug  is  a  contraindication  to  its  use. 

Bromid  of  potassium  may  be  used  in  connection  with  chloral,  or  in 
the  convalescent  stage  as  a  substitute  for  that  drug,  but  it  is  altogether 
too  mild  a  remedy  to  produce  any  appreciable  effect  in  the  more  active 
stages  of  the  disease. 

The  great  "  sweating,"  which  is  so  characteristic  a  symptom  of 
tetanus,  has  suggested  the  use  of  warm  baths  and  of  other  diaphoretics 
as  a  means  of  imitating  nature's  method  of  relief.  It  is  possible  that 
some  of  the  toxins  may  be  eliminated  in  this  way. 

So  far  as  local  treatment  is  concerned,  it  is  important  to  mention 
that  the  bacilli,  being  anaerobic,  lie  deep  if  in  a  state  of  activity.  Punc- 
tured wounds  should  be  thoroughly  laid  open  and  disinfected.  A  free 
discharge  from  the  wound  should  be  favored.  It  is  probable  that  the 
old-fashioned  flaxseed  poultice  has  warded  off  tetanus  in  former  times 
by  inducing  suppuration  in  the  wound.  A  dry  dressing  which  seals 
up  a  small  opening  is  a  source  of  danger.  The  most  careful  antisepsis 
and  asepsis  do  not  always  prevent  the  occurrence  of  tetanus.  Accord- 
ing to  Rose,  no  treatment  of  the  disease  is  of  so  much  value  as  the 
local  treatment.  This  is  shown  both  by  experiment  and  by  clinical 
experience.  It  destroys  the  bacilli  and  prevents  the  renewal  of  their 
toxic  products. 

Serum-therapy. — Both  Kitasato  and  Behring  contributed  largely 
to  the  introduction  of  a  serum.  They  produced  immunity  in  certain 
animals  by  the  injection  of  cultures  of  the  tetanus  bacillus,  whose 
activity  had  been  partially  destroyed  by  the  addition  of  trichlorid  of 
iodin.  The  serum  of  animals  thus  rendered  immune  could  be  used  on 
other  animals  as  a  protective  or  curative  agent.  The  exact  nature  of 
the  immunizing  substance  is  unknown,  but  has  been  called  "  Anti- 
tetanus" It  was  found  that  mice  inoculated  with  fragments  of  tissue 
containing  tetanus  spores  could  not  be  saved  even  by  the  use  of  50,000 
times  the  ordinary  immunizing  dose.  This  would  seem  to  show  that 
a  great  deal  depends  upon  whether  we  have  to  deal  with  the  toxins  or 
the  micro-organisms  themselves  in  a  given  case. 

The  mortality  of  tetanus  under  different  methods  of  treatment  is  very  difficult  to  deter- 
mine. The  rapidity  of  onset  after  inoculation  and  the  rapidity  of  progress  and  severity  of 
symptoms  vary  widely  in  different  cases,  and  no  measure  for  comparison  has  yet  been  discov- 
ered. The  statistics  before  the  introduction  of  the  serum  treatment  varied  from  40  to  as  high 
as  90  per  cent,  mortality  ;  and  when  divided  into  early  and  late  cases,  averaged  about  80 
per  cent,  for  the  early  and  40  per  cent,  for  the  late  cases,  or  60  per  cent,  for  all  cases.  The 
report  of  successful  cases  rather  than  fatalities  makes  the  true  estimate  of  any  new  method 
of  treatment  difficult ;  but,  on  the  other  hand,  the  cases  which  have  been  considered  suitable 
for  the  serum  treatment  up  to  the  present  time  have  been  the  more  severe  ones,  and  this  fact 
goes  to  offset,  to  a  certain  extent,  the  error  in  the  other  direction.  Moschcowitz  collected 
338  cases  of  tetanus  treated  with  serum  (  1900),  with  a  mortality  of  42  per  cent.,  and  con- 
cludes from  this  that  the  serum  treatment  has  been  of  conspicuous  benefit. 

Tetanus  antitoxin  is  generally  obtained  from  the  serum  of  a  horse 
rendered  immune  by  increasing  doses  of  tetanus  toxin.  Horse-serum 
becomes  thus  antitoxic  after  two  or  three  months  of  such  increasing 
toxin  injections.     Tetanus  antitoxin  is  usually  employed  as  a  blood- 


1 88  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

serum.  A  dry  powder  or  scales  are  sometimes  used.  This  is  pre- 
pared by  evaporating  the  scrum  to  dryness  over  sulphuric  acid.  One 
gram  of  the  powder  is  equal  to  io  c.c.  of  the  original  serum.  The 
serum  may  be  precipitated  with  alcohol.  The  dried  precipitate  thus 
obtained  is  the  material  used  by  Tizzoni. 

Dose  of  the  Serum. — This  is  based  upon  the  immunizing  power, 
which  should  be  in  the  proportion  of  I  :  i, 000,000.  One  cubic  centi- 
meter of  serum  should  be  a  sufficient  dose  to  protect  1,000,000  grams 
of  guinea-pig,  or  2000  guinea-pigs  each  weighing  500  grams,  from  the 
minimum  fatal  dose  of  tetanus  toxin  when  injected  eight  to  twelve 
hours  afterward.  The  dose  varies  according  to  the  weight  of  the 
individual,  and  also  according  to  its  use  as  a  prophylactic  or  curative 
agent. 

The  curative  treatment,  as  regards  the  amount  and  frequency  of 
injections,  is  based  upon  the  urgency  of  the  symptoms  and  the  subse- 
quent improvement.  The  shorter  the  period  of  incubation  and  the 
more  acute  the  case  the  larger  the  dose.  It  should  always  be  given 
as  early  as  possible. 

Many  of  the  serum  preparations  first  put  upon  the  market  were  too  weak  in  antitoxin 
to  be  effective,  but  the  many  products  now  available  are,  as  a  rule,  more  concentrated.  The 
strength  in  immunizing  power,  however,  is  not  uniform,  and  no  definite  dosage  can  be  laid 
down.  Behring  considers  a  dose  of  50°  units  essential  when  administered  by  subcutaneous 
injection  ;  and  of  a  serum  of  I  unit  to  the  cubic  centimeter,  500  c  c.  would  thus  be  re- 
quired for  the  initial  dose  ;  for  a  prophylactic  dose,  200  units  would  be  sufficient,  according 
to  this  estimate ;  and  it  may  be  said  that  the  use  of  the  serum  in  this  manner,  in  cases  where 
a  possible  infection  with  tetanus  is  feared,  is  coming  to  be  recognized  as  a  most  reasonable 
procedure.  Urticaria  and  transient  erythematous  eruptions  follow  frequently  upon  the  ad- 
ministration of  the  serum,  but  no  serious  results  need  be  feared  when  the  operation  is  per- 
formed with  proper  aseptic  precautions.  Injections  of  serum  are  ordinarily  made  under  the 
skin  of  the  abdomen,  back,  or  thigh.  When  a  more  immediate  effect  is  desired,  the  serum 
may  be  introduced  directly  into  a  vein,  and  thus  be  made  to  pass  more  rapidly  into  the  gen- 
eral circulation.  Intracranial  injection  of  the  serum  has  been  performed  in  a  number  of 
cases,  and  with  satisfactory  results.  This  procedure  is  based  on  the  experiments  of  Roux 
and  Borrel,  who  found  that  the  cure  of  tetamzed  animals  was  possible  with  very  small  doses 
of  antitoxin  when  the  serum  was  introduced  directly  into  the  substance  of  the  brain.  The 
operation  consists  of  the  removal  of  a  small  piece  of  bone  from  the  frontal  region,  on  one  or 
both  sides,  by  means  of  the  trephine  ;  5  to  7  c.c.  of  a  concentrated  serum  are  then  injected 
very  slowly  into  the  frontal  region  of  each  hemisphere.  The  serum  may  be  introduced 
directly  into  the  lateral  ventricles  ( Kocher),  or  merely  allowed  to  diffuse  itself  under  the 
dura.  The  operation  is  not  without  danger,  and  one  case  of  brain-abscess  and  one  of  hemor- 
rhage have  been  reported  as  following  this  method  of  administration,  but  the  greater  efficacy 
of  the  serum  when  applied  in  this  manner  seems  to  be  beyond  question.  Lumbar  puncture 
and  the  introduction  of  serum  into  the  spinal  canal  after  the  removal  of  15  or  20  c.c.  of 
spinal  fluid  has  also  been  performed,  but  the  results  have  not  been  so  satisfactory  as  from 
intracranial  injections.  The  intracranial  injection  of  serum  may  properly  be  reserved  for 
the  more  rapid  and  acute  cases  of  tetanus,  for  the  cure  of  which  subcutaneous  or  intravenous 
injections  have  proved  not  to  be  sufficient.  The  serum  treatment  must  be  supplemented 
by  other  forms  of  treatment,  and  may  be  used  in  connection  with  chloral,  chloroform,  car- 
bolic acid,  and  other  methods  of  treatment  for  the  relief  of  the  convulsive  symptoms. 

Carbolic=acid  Treatment. — A  form  of  treatment  which  enjoys 
popularity  in  Italy,  but  has  not  met  with  wide  acceptance  elsewhere,  is 
that  known  as  "  Baccelli's  treatment."  It  consists  in  the  repeated  ad- 
ministration of  carbolic  acid  by  subcutaneous  injection,  with  a  view  to 
the  neutralization  and  destruction  of  the  toxins  floating  in  the  general 
circulation.  Doses  of  10  to  30  drops  of  a  1  per  cent,  solution  of  car- 
bolic acid  may  be  given  every  three  or  four  hours  over  considerable 
periods  of  time  without  toxic  effects.     The  statistics  of  this  treatment 


TETANUS.  189 

as  compiled  by  Ascoli  give  most  gratifying  results.  At  the  hands  of 
other  surgeons  and  in  animal  experiments  the  carbolic-acid  treatment 
has  not  proved  so  effective  as  the  serum  treatment,  and  its  use  may  be 
reserved  for  those  cases  which  do  not  respond  to  the  serum  treatment 
or  when  serum  is  not  obtainable.  The  use  of  the  two  methods  together 
has  been  advised,  and  may  be  recommended  in  the  more  serious  cases. 
There  is  no  disease  in  which  the  comfort  of  the  patient  should  be 
studied  so  carefully.  Before  active  symptoms  have  set  in,  the  patient 
should  be  placed  alone  in  a  room  so  situated  as  to  be  quite  free  from 
disturbance.  Officious  nursing  should  be  avoided.  Nourishment  and 
stimulants  should  be  given  in  a  form  to  sustain  strength  while  produc- 
ing as  little  irritation  to  the  throat  as  possible.  Chloroform  may  be 
given  in  order  to  administer  nourishment  by  the  stomach-tube  if  neces- 
sary (Rose).  Many  acute  cases  may  thus  be  made  chronic.  Every 
day  added  to  the  patient's  life  after  the  first  week  of  the  disease  in- 
creases greatly  his  chances  of  recovery. 


CHAPTER   VIII. 

HYDROPHOBIA;  ANTHRAX;  GLANDERS;  ACTINOMYCO- 
SIS; MADURA-FOOT;  SNAKE-BITE;  INSECT-BITE. 

RABIES. 

Many  synonyms  for  this  disease  exist ;  of  these,  the  most  •impor- 
tant are  Hydrophobia,  Lyssa,  Furor,  Rabies,  Rabidity;  Wuth  (Ger.) ; 
Rage  {Fr.). 

Rabies  is  a  disease  of  man  and  certain  other  mammals  which  is 
communicated  from  one  individual  to  another  by  the  infection-bearing 
saliva  through  freshly  infected  wounds. 

The  history  of  the  disease  is  a  long  one,  and,  on  account  of  the 
characteristic  symptomatology,  is  less  complicated  by  confusion  with 
other  maladies  than  is  the  case  with  the  accounts  of  certain  other  dis- 
orders. Hippocrates  did  not  describe  the  disease  in  his  works  ;  but 
Aristotle,  a  half-century  later,  recognized  it  in  the  lower  animals. 
Celsus  gave  a  good  account  of  rabies  in  the  first  Christian  century. 

For  centuries,  no  very  essential  progress  in  the  knowledge  of  the 
disease  encouraged  its  observers,  so  that  many  medical  men  began  to 
lose  faith  in  its  existence  as  a  separate  nosological  entity.  Bosquillon 
in  1802  advanced  as  a  positive  belief  the  idea  that  hydrophobia  was  a 
mere  chimera.  Experimental  inoculation  researches  a  few  years  later 
dispelled  this  notion  forever,  and  the  more  recent  extensive  researches 
of  Pasteur  on  its  etiology,  prevention,  and  cure,  have  made  hydropho- 
bia a  comparatively  well-studied  disease. 

Distribution  and  Frequency. — Since  almost  all  the  mammalian  animals  are  suscep- 
tible to  the  disease  and  can  transmit  it  to  man,  and  since  man  is  attended  in  all  parts  of  the 
habitable  globe  by  these  animals,  the  disease  is  distributed  over  the  whole  world.  No  land 
is  known  to  be  immune  to  rabies,  since  both  hot  and  cold  climates  have  their-records  of  the 
disease.  Australia  is  said  to  be  free  of  the  disease,  supposedly  on  account  of  a  six  months' 
quarantine  to  which  all  dogs  are  subjected  before  admission  to  the  island. 

Besides  dogs,  cats,  wolves,  horses,  swine,  and  cattle,  which  are  the  most  common  agents 
for  the  transmission  of  infection,  foxes,  jackals,  asses  and  mules,  sheep,  rabbits,  and  man 
are  also  responsible.  Dogs,  of  course,  cause  the  disease  most  frequently  ;  but  not  only  on 
account  of  opportunity,  since  the  saliva  of  infected  dogs  is  thought  to  be  usually  more  viru- 
lent than  that  of  other  animals.  Epidemics  of  rabies  are  usually  traceable  to  one  originally 
infected  animal  which  has  transmitted  the  disease  to  others.  The  cases  of  so-called  spon- 
taneous rabies  are  doubtless  due  to  the  original  infection  of  dogs  or  cats  by  rats  or  other 
animals  living  in  hiding  from  man.  Hoegyes  explains  the  frequency  of  outbreaks  in  summer 
by  the  fact  that  man  is  at  that  season  more  exposed  to  infection  by  an  outdoor  life,  often 
in  close  association  with  the  lower  animals. 

The  number  of  cases  annually  occurring  is  sufficiently  indicated  by  the  fact  that,  between 
the  years  1887  and  1895,  14,296  cases  were  treated  at  the  Pasteur  Institute  in  Paris  ;  while 
in  the  Buda-Pesth  Institute,  from  April  15,  1890,  to  Dec.  31,  1895,  4961  cases  applied  for 
aid.  Of  course,  many  of  the  cases  applying  for  treatment  doubtless  had  been  bitten  by 
animals  not  actually  rabid  ;  but  even  deducting  these,  the  number  is  large. 

Etiology. — Opportunity  for  infection,  of  course,  counts  for  much  in  the  causation  of  the 

disease.      Those  individuals  who,  like  farmers  and  laborers,  are  much  in  the  open  air  and 

are  associated  with  the  domesticated  animals  furnish  the  greatest  contingent  of  cases.     Nearly 

twice  as  many  males  are  infected  as  females,  for  the  same  reason.     Children,  unable  to 

190 


RABIES.  I9I 

escape  from  infected  animals  or  to  protect  themselves  when  attacked,  are  much  more  fre- 
quently bitten  than  their  elders.  The  part  of  the  body  wounded  is  of  etiological  importance. 
The  limbs  are  protected  by  the  clothing,  which  tends  to  prevent  deep  bites  and  to  wipe  off 
the  virus  from  the  teeth  of  the  animal  before  they  enter  the  flesh  of  the  victim.  Besides,  the 
face  and  other  parts  of  the  head  being  located  nearer  the  centers  of  the  nervous  system  and 
of  the  circulation,  afford  better  opportunities  for  the  virus  to  reach  the  vital  parts. 

Although  experimental  research  has  not  been  successful  in  estab- 
lishing definitely  the  biology  of  the  infectious  agent  in  rabies,  it  has 
done  much  to  determine  the  conditions  under  which  infection  takes 
place,  the  life  history  of  the  disease,  and  above  all  it  has  demonstrated, 
through  the  brilliant  researches  of  Pasteur  and  his  pupils,  the  fact  that 
an  immunity  against  the  disease  may  be  established  and,  as  we  shall 
see,  may  be  utilized  in  the  practical  treatment  of  the  disease.  Before 
Pasteur's  time,  it  had  been  shown  by  several  investigators  that  the  dis- 
ease is  really  transmitted  by  the  infected  saliva.  Galtier  in  1879  pub- 
lished the  results  of  experimental  studies  proving  that  the  disease  as  it 
occurs  in  dogs  may  be  transmitted  to  rabbits,  affording  a  ready  means 
of  determining  the  virulence  of  the  saliva  obtained  from  dogs  suspected 
of  rabies,  especially  as  the  period  of  incubation  in  rabbits  is  much 
shorter  than  in  dogs.  It  was  Pasteur,  however,  who  showed  that  the 
virus  of  rabies  exists  in  the  central  nervous  system  and  is  most  concen- 
trated in  the  medulla  oblongata.  The  inference  was  quickly  drawn  by 
Pasteur  that  the  inoculation  of  the  virus  into  the  central  nervous  system 
would  be  more  rapidly  and  certainly  followed  by  the  disease  than  if  the 
subcutaneous  method  were  employed.  Thus  was  found  a  ready  and 
sure  means  of  producing  the  disease,  in  almost  every  case,  by  injecting 
the  triturated  spinal  cords  or  medullas  of  infected  animals  into  the  sub- 
dural spaces  of  other  animals  susceptible  to  the  disease.  Intraocular 
injections  are  almost  as  certain  in  their  results.  Applying  the  injected 
matter  directly  beneath  the  sheaths  of  the  principal  nerve-trunks  is  a 
valuable  experimental  method.  When  the  infectious  matter  is  intro- 
duced into  the  subcutaneous  tissue,  it  is  carried  centripetally  to  the 
central  nervous  system  along  the  nerve-sheaths.  Having  reached  the 
central  nervous  system,  it  is  then  redistributed  to  the  periphery  by  way 
of  nerve-sheaths. 

The  gross  anatomical  findings  in  rabies  are  insignificant  in  pro- 
portion to  the  great  gravity  of  the  disease.  The  vascular  engorgement 
seen  is  probably  due  to  the  struggles  of  the  victim  during  the  stage  of 
excitation.  Even  microscopically  nothing  characteristic  of  rabies  can 
be  found.  Certain  degenerative  changes  are  noted  in  the  cells  of  the 
central  nervous  system,  especially  the  multipolar  cells  of  the  anterior 
horns.  Cellular  infiltrations  in  other  cases  are  noted  in  the  gray  sub- 
stance of  the  cord.  The  pathologist  must  therefore  depend  for  his 
diagnosis  rather  upon  the  results  of  inoculation  experiments,  and  for 
this  purpose  the  brain  and  spinal  cord  may  be  reserved. 

The  symptoms  of  the  disease  in  inoculated  animals  are  of 
especial  practical  importance  on  account  of  their  bearing  on  the  infec- 
tion of  human  beings  attacked  by  such  animals.  The  form  of  rabies 
occurring  in  80  or  85  per  cent,  of  the  cases  in  dogs  is  characterized  by 
three  stages — an  initial  stage,  a  stage  of  irritation,  and  a  stage  of  paral- 
ysis. Incubation  in  dogs  inoculated  by  bites  varies  much  in  duration, 
but  on  the  average  is  sixty  days.      Temperature-elevation  is  noted  as 


I92  INTERNATIONAL     TEXT-BOOK  OF  SURGERY. 

the  first  sign  of  the  disease,  lasting  a  half  to  three  clays.  The  dog  then 
becomes  dull,  sad,  unfriendly.  The  appetite  becomes  poor  and  later 
abnormal,  the  clog  biting,  chewing,  and  even  swallowing  paper  and 
trash   of  various  sorts. 

The  irritation  or  rabid  stage  follows  upon  the  initial  stage  by  some- 
what gradual  exaggeration  of  the  preceding  symptoms.  This  is  the 
stage  of  madness.  The  dog  is  more  excitable,  distrustful,  and  snap- 
pish. His  voice  is  hoarse,  and  he  howls  rather  than  barks.  Anxious 
to  escape  from  confinement,  he  runs  away  aimlessly  when  released, 
snapping  and  biting  at  every  man  or  animal  in  his  way.  Three  or  four 
days  pass  before  the  excitation  gives  place  to  paralysis  of  the  exhausted 
nerve-centers.  The  dog  appears  weak,  runs  unsteadily,  breathes  rap- 
idly and  irregularly ;  his  tongue  hangs  out  of  his  mouth,  from  which 
drips  a  bloody,  foamy  saliva.  Paralysis  is  soon  followed  by  death.  In 
the  minority  of  cases  (15  to  20  per  cent.)  the  stage  of  excitation  is  so 
abbreviated  as  to  be  unnoticed,  or  is  even  altogether  absent.  The 
animal  is  first  considered  ill  when  the  symptoms  of  weakness  or 
even  of  paralysis  are  observed.  This  is  known  as  the  quiet  form  of 
rabies.  When  well-marked  signs  of  rabies  are  present,  the  disease  is 
almost  invariably  fatal  in  either  of  these  forms. 

It  will  thus  be  seen  that  the  diagnosis  of  rabies  in  the  dog, 
while  usually  easy,  may  require  the  observation  of  a  competent  veter- 
inary surgeon  to  distinguish  it.  In  the  absence  of  such  aid  and  in 
doubtful  cases  the  dog  may  be  killed,  and  the  brain  and  spinal  cord 
removed  as  nearly  aseptically  as  possible.  The  specimen  is  sealed  up 
aseptically  and  transmitted  immediately  to  the  expert  in  rabies.  By 
him  the  medulla  oblongata  will  be  rubbed  up  with  physiological  salt 
solution,  and  a  portion  of  this  material  injected  into  the  subdural  space 
of  a  rabbit's  brain.  If  rabies  virus  is  present,  it  will  with  certainty 
cause  the  disease  to  appear  in  the  inoculated  animal. 

Van  Gehuchten  has  recently  noted  characteristic  changes  in  the 
cerebral  ganglia,  especially  of  the  vagus  and  trigeminus,  and  in  the 
spinal  and  sympathetic  ganglia,  by  the  postmortem  examination  of 
which  it  is  possible  to  diagnosticate  rabies.  The  nerve-cells  are  de- 
stroyed and  are  replaced  by  inflammatory  tissue. 

The  symptoms  of  rabies  in  man  correspond  well  with  those  of 
the  disease  in  dogs.  The  incubation  stage  may  be  as  short,  in  rare 
cases,  as  thirteen  or  fourteen  days.  Usually  death  takes  place  between 
the  twentieth  and  sixtieth  days.  The  incubation  may  in  rare  instances  be 
very  long — six,  thirteen,  fourteen,  twenty-two  months.  It  is  of  interest 
from  a  therapeutic  point  of  view  that  the  incubation  period  is  apparently 
lengthened  by  depressing  influences.  The  wounds  seem  to  heal  about  as 
rapidly  as  ordinary  wounds  exposed  to  similar  conditions.  It  is  only 
severe  contusion,  pus-infection,  and  cauterization  that  delay  healing. 
A  local  reddening  of  the  scar  seems  to  occur  during  the  initial  stage, 
associated  with  such  signs  of  nervous  disturbance  as  centripetally  radi- 
ating pains,  burning,  tickling,  and  other  evidences  of  paresthesia. 
Anesthesia  and  hyperesthesia,  also,  at  times  give  evidence  of  dissemi- 
nation of  the  virus  along  the  nerve-trunks.  The  stage  of  nervous  ex- 
citation is  indicated  by  mental  excitement,  spasms  of  the  respiration 
and  deglutition  muscle-groupSj  and  this  stage  is  in  turn  succeeded  in 


RABIES.  193 

man  by  the  stage  of  exhaustion  and  paralysis.  Before  the  onset  of 
active  symptoms,  the  patient  seems  melancholy  and  depressed ;  then 
he  becomes  restless  and  eager  to  walk  about.  Such  moods  of  depres- 
sion may  be  succeeded  by  short  periods  of  joyous  excitation,  which 
are  again  followed  by  depression. 

In  the  stage  of  excitement,  or  hydrophobia,  respiration  becomes 
difficult,  sighing,  and  anxious,  and  the  bystanders  note  with  especial 
horror  the  patient's  inability  to  drink  on  account  of  spasms  of  the 
pharyngeal  muscles.  As  the  disease  progresses,  even  the  sound  of 
running  water,  or  the  suggestion  of  it,  will  superinduce  these  spasms. 
The  patient,  dreading  the  onset  of  the  contractions,  fears  to  attempt 
drinking,  hence  the  term  hydrophobia  (from  Greek  words  meaning 
"  water  "  and  "  to  fear  ").  Spasms  of  other  muscle-groups  commonly 
occur,  and  hypersensitiveness  of  the  various  sense-organs  is  often  seen. 
Hallucinations  may  thus  arise.  Consciousness  remains  undisturbed, 
except  during  the  exacerbations,  almost  to  the  end  of  life.  The 
horror  of  the  disease  is  thus  fully  appreciated  by  the  unfortunate 
victim.  The  flow  of  saliva  is  increased,  and,  as  it  is  the  chief  vehicle 
of  infection,  much  care  must  be  exercised  to  prevent  the  attendants 
and  bystanders  from  being  inoculated.  In  delirium  the  patient  may 
eject  the  saliva,  almost  as  if  he  had  the  intention  to  infect  others.  It 
is  a  popular  error  that  hydrophobic  patients  imagine  themselves  to  be 
dogs,  and  bark,  bite,  and  snap  at  the  attendants.  Elevation  of  temper- 
ature, priapism,  and  satyriasis  are  observed. 

While  the  stage  of  excitation  lasts  from  one  and  a  half  to  three 
days,  the  final  stage  of  paralysis  may,  in  man,  be  altogether  wanting 
or  may  last  but  a  few  minutes.  It  is  usual  for  the  patient  to  lie  re- 
laxed for  two  to  eighteen  hours  before  death.  In  man,  as  in  lower 
animals,  a  paralytic  form  of  rabies  exists,  in  which  the  active  symptoms 
of  the  disease  are  but  slightly  marked,  while  the  paralytic  phenomena 
appear  with  especial  prominence. 

The  diagnosis  of  rabies  often  involves  the  exclusion  of  hystero- 
epilepsy,  tetanus  (in  which  spasms  of  the  muscles  of  the  throat  often 
occur),  delirium  tremens,  epilepsy,  sunstroke,  poisoning — especially  by 
datura  stramonium — and  brain-tumors. 

The  prognosis  in  wounds  inflicted  by  rabid  animals  is  variable.  In 
only  15  or  20  per  cent,  of  the  cases  does  the  disease  break  out  at  all ; 
but  when  the  disease  is  well  established  in  a  human  subject,  it  almost 
inevitably  destroys  life. 

Treatment  of  rabies  by  prophylaxis,  therefore,  is  especially  impor- 
tant. This  involves  decreasing  the  number  of  dogs  in  communities 
by  taxation,  controlling  dogs  by  registration,  by  the  use  of  muzzles, 
and  by  excluding  them  from   certain  public  places. 

When  persons  are  bitten  by  animals  known  or  suspected  to  be 
rabid,  the  animal  should  either  be  killed  at  once  or  confined  and  care- 
fully watched  for  pronounced  signs  of  the  disease.  In  the  former 
case  the  central  nervous  system  is  removed,  and,  parts  of  it  (medulla) 
having  been  rubbed  up  with  sterilized  salt  solution,  the  material  thus 
obtained  is  injected  into  a  rabbit's  subdural  spaces.  The  disease  will 
thus  be  speedily  transmitted  to  the  inoculated  animal,  giving  us  a  well- 
nigh  infallible  diagnostic  test.  But  one  should  not  wait  until  this  test 
13 


i94 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


is  completed  before  immunizing  the  person  bitten.  The  patient  is 
usually  sent  to  a  branch  office  of  the  Pasteur  Institute.  Such  labora- 
tories are  located  in  all  civilized  countries. 

Immunization  is  effected  by  successive  injections  of  virus  which  has 
been  weakened  in  virulence  in  various  ways.  Gradually  the  strength 
of  the  virus  is  increased  until  the  maximum  is  reached,  when  the 
patient  is  declared  insusceptible  to  the  action  of  the  infectious  agent. 
In  this  way  more  than  50,000  persons  were  treated  between  1885  and 
1895,  with  astonishingly  good  results.  The  inoculations  themselves 
are  entirely  harmless.  The  method  employed  at  the  Parisian  Pasteur 
Institute,  where  the  virus  is  diminished  in  activity  by  drying  the  spinal 
cords  from  which  the  emulsion  is  made,  is,  for  wounds  of  the  extremi- 
ties, as  follows : 


Day  of 
Treatment. 


Period  during  whit  h 

Medulla  has  been  Dried. 
14  days  ) 
13  days  I 
J  12  days  I 
(II  days  f  '  '  ' 
I  10  days  1 
\  9  days  I 
f    8  days 


Quantity  of 
Emulsion  used. 

3  can.  (tt\,4S). 
3  c.cm.    " 
3  c.cm.    " 


9 
10 
II 
12 
l3 
14 
15 


days 
days 
days 
days 
days 
days 
days 
days 
days 
days 
days 
days 


.  3  c.cm. 


X32) 


2  c.cm. 
2  c.cm.  " 
2  c.cm.  " 
2  c.cm.    " 

1  c.cm.  (TTLi6). 

2  c.cm.  (n\j2). 
2  c.cm.    " 

2  c.cm.  " 
2  c.cm.  " 
2  c.cm.  " 
2  c.cm.    " 


When  wounds  have  occurred  about  the  head,  the  treatment  given 
is  somewhat  stronger — the  emulsions  of  stronger  virus  being  admin- 
istered earlier. 

The  value  of  cauterization  of  wounds  is  denied  by  most  authorities 
except  when  the  operation  is  performed  within  one  hour  after  the 
injury.  Cabot  has  recently  employed  with  considerable  success  in  ex- 
perimentally infected  rabbits  chemically  pure  fuming  nitric  acid.  Cau- 
terization is  said  to  be  of  service  even  up  to  twenty-four  hours  after 
the  infliction  of  the  wound. 


ANTHRAX. 

Synonyms. — Pustula  maligna,  Carbunculus  contagiosus,  Wool- 
sorters'  disease,  Splenic  fever;  Milzbrand,  Hadern-Krankheit  (Ger.) ; 
Charbon  (Fr.). 

The  history  of  anthrax  in  olden  times  is  complicated  by  the  con- 
fusion with  it  of  various  cutaneous  maladies  associated  with  a  tendency 
to  destruction  of  the  skin.  But  its  more  modern  history  is  a  more 
profitable  study,  worthy  of  especial  consideration  because  this  was  the 
first  disease  affecting  man  to  receive  full  bacteriological  study.  No 
other  infectious  process  has  been  so  frequently  the  object  of  research, 
and  the  results  of  these  researches,  conducted  by  the  greatest  masters 


ANTHRAX.  195 

of  modern  methods,  have  afforded  paradigms  for  the  investigation  of 
numerous  other  diseases  of  the  same  type. 

Pollender  found  vibrio-like  bodies  in  the  blood  of  anthrax  animals  as  early  as  1855. 
Two  years  later,  Branell  found,  besides  these  rod-like  organisms,  small  vesicular  and  dust- 
like bodies.  Branell  was  the  first  to  make  inoculation  experiments  with  a  view  to  deter- 
mining the  infectious  character  of  these  bodies  ;  but  it  is  to  the  persistent  and  courageous 
work  ol  Davaine,  appearing  in  numerous  communications  to  the  Paris  Academy  of  Sciences 
from  1S64  to  1873,  that  we  owe  the  real  foundation  of  our  modern  doctrine  of  anthrax,  and 
hence  of  the  wound-infection  diseases  in  general.  It  was  he  who  first  showed  that  the  rod- 
like bodies  of  Pollender  and  Branell  were  living  organisms.  He  contended  that  these 
bodies  were  the  cause  of  the  disease,  and  showed  that  the  blood  of  affected  animals,  if  it 
contained  these  bodies,  was  capable  of  transmitting  the  disease.  Absolute  demonstration 
of  the  truth  of  his  convictions  could  not  be  made  by  Davaine  for  the  lack  of  culture-methods, 
which  were  then  unknown,  and  the  greatest  living  authorities  disputed  his  theory  until 
F.  Cohn  and  Robert  Koch  proved  the  spores  to  be  a  link  in  the  continuity  of  life  in  the 
anthrax  microbe.  Koch,  Pasteur,  and  Klebs  finally  added  absolute  proof  by  the  inocula- 
tion of  pure  cultures. 

Etiology. — Referring  the  reader  to  the  chapter  on  Bacteriology 
for  a  technical  consideration  of  the  Bacillus  anthracis,  we  pass  to  a  con- 
sideration of  the  etiology  of  the  disease,  an  elementary  knowledge  of 
which  is  essential  to  our  stud}'. 

Splenic  fever  is  a  disease  common  to  man  and  certain  of  the  lower 
animals.  It  is  through  association  with  infected  animals  or  their  car- 
casses, as  a  rule,  that  man  is  infected. 

The  bodies  of  animals,  usually  cattle,  horses,  sheep,  etc.,  dying  in  pastures  or  marshy 
lands  are  often  neglected  by  ignorant  farmers,  and  the  anthrax  bacteria  are  scattered  as  the 
bodies  decompose.  The  spores  of  the  microbe  may  remain  for  long  periods  inactive  in  the 
buried  or  partly  covered  flesh,  and  may  be  distributed  to  a  distance  by  flood-waters.  In 
this  way,  whole  pastures  and  water-courses  may  become  infected,  and  other  animals  grazing 
over  the  land  contract  the  disease  by  contact  with  the  spores.  Even  if  the  body  of  the 
animal  is  buried  just  beneath  the  surface,  the  bacteria  may  be  brought  up  by  earth-worms, 
snails,  and  beetles.  The  older  recommendation  to  bury  the  bodies  of  animals  dead  of 
anthrax  at  least  one  meter  deep  is  best  replaced  by  the  rule  that  such  bodies  should  be 
destroyed  by  fire.  Infected  districts  can  be  purified  only  after  considerable  time  by  thus 
destroying  the  carcasses  and  by  confining  susceptible  animals  to  other  feeding-grounds. 

The  animals  susceptible  to  anthrax  are  chiefly  the  herbivora,  especially  sheep  and  cattle. 
Algerian  sheep,  however,  possess  a  certain  immunity  against  the  disease.  Horses  are  less 
frequently  affected  ;  but  it  is  said  that  the  disease  occurs  among  Russian  horses,  oftentimes 
in  epizootic  form.  Wild  animals  of  the  deer  and  antelope  families  are  occasionally  subject 
to  the  disease.  Such  rodents  as  guinea-pigs,  mice,  and  rabbits  are  quite  subject  to  the 
disease,  but  the  varieties  of  rats  are  unequally  susceptible.  Infrequently  dogs,  cats,  foxes, 
and  hares  are  attacked.  Ducks,  pigeons,  and  crows  are  but  slightly  susceptible,  while 
chickens  are  more  readily  attacked.      Cold-blooded  animals  are  quite  resistant. 

The  disease  is  transmitted  to  man  from  infected  animals  ;  and  it 
facilitates  the  study  of  this  part  of  the  etiology  to  premise  that  the 
bacteria  gain  admission  by  way  of  skin-injuries,  by  inhalation  of  in- 
fected dust,  and  by  the  ingestion  of  infected  foods. 

Those  who  are  engaged  in  handling  hides  are  likely  to  infect  small 
abrasions  of  the  hands  or  of  the  face.  Wool-sorters  in  England, 
handling  wool  from  all  parts  of  the  world,  are  often  affected  with  an- 
thrax of  the  respiratory  passages.  Butchers  are  liable  to  infection  of 
cuts.  Veterinaries  are  inoculated  while  treating  the  disease.  Farmers 
sometimes  contract  the  disease  in  handling  the  living  animals  or  their 
carcasses.  Pathologists  have  frequently  been  infected  while  mak- 
ing post-mortems  of  experimental  animals  dead  of  the  disease.  The 
story  is  related  by  Lubarsch  that  one  young  pathologist  contracted  the 
disease  by  smoking,  while  conducting  an  autopsy  on  a  cock  which  he 


I96  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

had  killed  with  anthrax.  The  cigar,  frequently  handled  and  replaced 
in  the  mouth,  was  doubtless  the  carrier  of  the  microbes.  Rarely  is 
the  disease  conveyed  by  infected  foods. 

The  atrium  of  the  microbe  in  man  is  usually  an  abrasion  of  the  skin, 
but  the  bacteria  can  enter  by  the  lungs  and  by  the  intestines  without 
the  occurrence  of  wounds.  The  injuries  of  the  skin  may  be  produced 
by  the  infection-bearing  object,  or  the  inoculation  may  occur  upon  a 
wound  already  made  in  the  absence  of  granulations.  Flies  are  said  to 
transmit  the  disease  (Koch),  and  the  bristles  from  which  brushes  are 
made  have  frequently  carried  the  microbe.  Surgeons  have  repeatedly 
conveyed  the  infection  by  using  imperfectly  sterilized  catgut  from  sheep 
suffering  from  splenic  fever. 

The  pathological  anatomy  of  anthrax  in  man  consists  essentially 
in  necroses  and  serous,  serofibrinous,  and  seropurulent  inflammations,  as 
well  as  hemorrhages  (Lubarsch  and  Frank). 

The  most  generally  known  lesion  of  splenic  fever  in  man  is  the 
initial  lesion  at  the  site  of  infection  when  the  skin  is  first  invaded — the 
"  carbuncle  "  or  "  pustule."  A  small  translucent  vesicle  appears  at  the 
site  of  inoculation,  turning  to  a  bluish-red  color,  and  by  bursting  is  con- 
verted into  a  small,  irritable,  itching  tumefaction.  It  is  characteristic  of 
this  little  ulcer  that,  while  its  edges  are  elevated,  its  center  is  depressed 
and  of  a  dirty-black  or  purple  color,  due  to  necrosis  of  the  tissues.  The 
neighboring  skin  is  often  reddened  and  infiltrated.  When  the  central 
scab  is  raised,  there  exudes  'a  thin  fluid  which  contains  anthrax  bacilli  in 
greater  or  less  numbers.  This  characteristic  appearance  often  suffices 
to  clinically  identify  the  disease,  and  to  suggest  an  examination  for  the 
specific  agent  of  the  disease. 

Microscopical  examinations  show  active  inflammation  going  on  in 
the  affected  skin,  the  corium  and  papillary  layer  being  infiltrated  with  a 
sanguinolent,  cellular  exudate.  Although  the  bacteria  can  penetrate 
into  the  deeper  layers  of  the  corium,  they  lie  chiefly  in  the  external 
portions  of  the  corium  and  in  the  papillary  bodies. 

If  the  primary  lesion  occurs  in  the  intestinal  canal,  the  general 
appearance  is  much  like  that  of  the  cutaneous  lesion,  a  similarity  which 
in  the  main  is  borne  out  by  microscopical  examination. 

In  the  case  of  primary  pulmonary  infection,  the  spores  are  inhaled 
with  dust  and  become  arrested  in  the  bronchial  tubes  and  alveoli,  where 
they  develop.  They  are  then  observed  in  the  connective  tissue  and  the 
lymphatic  spaces  of  the  organ.  Inflammation,  edema,  and  the  exuda- 
tion of  a  bloody  serous  fluid  in  the  pleural  cavities  are  commonly 
observed  (Ziegler). 

Should  the  bacteria  grow  in  the  circulating  blood,  they  are  found  in 
the  most  distant  parts  of  the  body,  and  in  especially  great  numbers  in 
the  capillaries  of  the  abdominal  viscera.  In  the  lower  animals  the 
tendency  is  for  the  disease  to  spread  by  way  of  the  blood,  while  the 
primary  lesion  is  by  no  means  so  characteristically  developed  as  in  man. 
Death  occurs,  usually,  as  a  result  of  intoxication  by  the  poison  charac- 
teristic of  the  bacillus,  the  old  theory  of  a  mechanical  occlusion  of 
capillaries  important  to  the  vegetative  functions  having  been  abandoned 
as  untenable. 

The  symptoms  and  course  of  anthrax  in  man  depend  to  a  great 


ANTHRAX.  197 

extent  on  the  point  of  entry  of  the  disease.  In  the  form  beginning  with 
a  cutaneous  lesion,  the  face  and  head  are  most  frequently  attacked,  then 
the  upper  extremities,  the  neck,  the  trunk,  and,  finally,  the  lower 
extremities.  While  a  single  carbuncle  is  usually  observed,  numerous 
instances  are  recorded  in  which  two  or  four  lesions  were  observed  in 
simultaneous  evolution.  The  period  of  incubation,  lasting  usually  two 
or  three  days,  is  very  imperfectly  characterized  by  malaise,  dulness, 
belching,  indigestion,  and  perhaps  a  slight  febrile  movement.  Only  two 
or  three  days  more  are  consumed  after  the  appearance  of  the  pustule 
before  the  disease  extends  beyond  the  purely  local  stage,  since  the 
lymph-glands  of  the  affected  region  become  enlarged  and  painful,  and 
the  skin  over  them  becomes  edematous.  The  fever,  meanwhile,  has 
become  higher,  the  dulness  greater,  and  the  gastric  symptoms  more 
pronounced. 

The  disease  may  now  terminate  in  recovery  or  in  extension  of  infec- 
tion and  death.  In  the  first  instance,  the  scab  over  the  carbuncle  falls 
off  a  clean  granulating  surface  is  left,  and  the  wound  heals  by  the  usual 
process  of  epidermization.  When  death  ensues,  it  follows  as  a  result 
of  general  infection.  Death  may  occur  early — even  in  two  or  three 
days,  when  the  infection  has  been  especially  violent.  Usually  at  least 
four  or  six  days  elapse.  The  gastric  symptoms  are  pronounced,  the 
vital  powers  are  greatly  depressed,  and  pains  are  felt  in  the  head  and 
limbs.  Chills  are  followed  by  high  fever.  In  many  cases,  though  not 
constantly,  the  spleen  is  enlarged.  The  appearance  of  the  carbuncle  is 
such  as  to  indicate  no  healthy  reaction ;  the  skin  about  it  is  blue,  cool, 
and  doughy  to  the  touch.  The  general  weakness  increases,  although 
the  consciousness  often  remains  unclouded  to  the  end.  The  severity 
of  the  general  symptoms  increases  rapidly,  the  vomitus  is  bloody,  the 
extremities  become  cool,  the  pulse  continuously  weaker,  thinner,  and 
scarcely  perceptible.  The  patient  complains  of  great  dyspnea,  a  profuse 
cool  sweat  appears,  the  voice  weakens,  the  temperature  falls,  and  death 
results  under  increasing  somnolence  and  gradual  loss  of  consciousness. 
Sometimes  delirium,  coma,  or  convulsions  close  the  scene  (Koranyi). 

A  second  form  of  the  disease,  known  as  malignant  edema  (cedeme 
charbonneux),  begins  as  a  doughy,  almost  translucent  swelling,  most 
frequently  observed  over  the  upper  eyelid.  The  swelling  is  very  great, 
causing  the  eyeball  to  disappear  completely.  General  infection  may 
take  place  from  this  primary  focus  of  the  disease,  and  its  outcome  is 
usually  fatal. 

In  the  gastro-intestinal  form  of  the  disease  death  usually  occurs. 
It  is  ushered  in  with  a  prodromal  stage  often  lasting  but  a  few  hours. 
Weakness,  headache,  vertigo,  and  vague  pains  are  followed  by  the 
active  stage  of  the  disease,  in  which  complete  anorexia,  great  thirst, 
nausea,  and  vomiting  occur.  The  abdomen  becomes  distended  and 
tender,  the  pulse  weak  and  thready ;  cold  sweat  appears,  and  convul- 
sions are  often  noted.  Perforation  of  the  intestines  may  lead  to  death 
by  peritonitis. 

The  diagnosis  of  splenic  fever  is  not  difficult  to  make  where  the 
typical  carbuncle  is  observed,  leading  at  once  to  a  search  for  the  an- 
thrax bacillus.  Malignant  edema  may  be  recognizable  only  by  exclu- 
sion when  the  imperfect  development  of  the  primary  carbuncle  does 


[0,8  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

not  supply  a  clue.  Intestinal  anthrax  cannot  be  diagnosticated  in  the 
absence  of  an  anamnesis  referring  to  the  ingestion  of  infected  meat  or 
milk.  Intestinal  and  pulmonary  anthrax  are,  before  death,  scarcely 
demonstrable  without  the  discovery  of  the  bacillus.  This  organism 
must  be  sought  for  by  culture-methods  wherever  its  presence  is 
suspected. 

The  prognosis  is  least  grave  in  the  cutaneous  form  of  anthrax, 
where  the  local  lesion  is  well  marked  and  lends  itself  to  local  thera- 
peutic measures.  Malignant  edema  gives  a  less  favorable  outlook, 
and  cured  cases  are  referred  to  as  rarities.  So  far  as  the  cases  are 
recognizable,  the  intestinal  form  of  anthrax  is  very  fatal.  But  of  all 
forms,  the  pulmonary  type  gives  the  highest  death-rate — 50  per  cent, 
according  to  Eppinger;  75  to  80  per  cent,  as  estimated  by  British 
writers. 

The  treatment  by  prophylaxis  is  of  the  highest  importance — first 
by  burning  the  bodies  of  all  infected  animals,  and  second  by  sterilizing, 
where  possible,  the  various  products  of  unknown  animals  which  may 
carry  the  contagion — e.  g.,  hair,  wool,  bristles,  hides,  catgut. 

Pasteur's  method  of  immunizing  sheep  by  the  inoculation  with  miti- 
gated virus  has  been  found  practicable  in  limiting  the  spread  of  the 
disease  in  Australia  and  in  France,  and  is  worthy  of  further  application 
among  susceptible  domestic  animals. 

Cauterization  of  the  primary  lesion  by  a  large  number  of  agents  has 
been  tried  with  varying  success.  But  a  better  plan  is  the  excision  with 
the  knife,  as  suggested  by  Fournier.  The  incision  is  to  be  carried 
through  perfectly  healthy  tissues.  Bryant  and  Baker  cauterize  the 
newly  exposed  surface.     Verneuil  extirpated  with  the  thermocautery. 

In  case  excision  is  unavailing  in  stopping  the  disease  or  cannot  be 
employed,  quinin  in  stimulating  doses  is  to  be  tried.  Leube  recom- 
mends 30  gr.  (2  gm.)  of  the  hydrochlorate  with  15  gr.  (1  gm.)  of  car- 
bolic acid,  divided  into  ten  doses,  to  be  given  in  one  day.  Ipecacuanha 
is  recommended  for  the  intestinal  form,  followed  by  calomel.  It  is  to  be 
hoped  that  an  antitoxic  serum  will  soon  be  provided  for  this  disease, 
as  has  been  experimentally  attempted  by  Emmerich.  Symptomatic 
remedies  are,  of  course,  indicated  in  the  systemic  forms  of  anthrax  as 
elsewhere. 

Strubell  has  recently  successfully  treated  two  cases  of  anthrax  with 
very  hot  cataplasms  and  hypodermic  injections  of  3  per  cent,  carbolic 
acid  beneath  and  around  the  point  of  infection. 

GLANDERS. 

Synonyms. — Malleus  humidus,  Farcy;  Morve,  Farcin  (Fr.);  Rotz 
(Ger.).  Glanders  is  an  infectious  disease  of  horses  and  other  mam- 
mals, transmissible  to  man,  and  characterized  pathologically  by  the 
deposit  of  nodular  lesions  in  various  tissues.  The  disease  has  been 
recognized  as  a  separate  nosological  entity  for  a  long  period,  but  its 
specific  causative  agent,  the  bacillus  of  glanders,  was  not  identified 
until  its  recent  discovery  by  Loffler. 

In  the  horse  the  disease  produces  lesions  and  symptoms  described 
by  Youatt  as  follows  : 


GLAATDERS.  1 99 

"The  earliest  local  symptom  is  a  nasal  discharge,  which  consists  of  an  increased  secre- 
tion, small  in  quantity,  and  flowing  constantly.  It  is  of  an  aqueous  character,  mixed  with 
a  little  mucus.  It  is  not  sticky  when  first  recognized,  but  becomes  so  afterward,  having  a 
peculiar  viscidity  and  glueyness.  The  discharge  soon  increases  in  quantity,  and  in  the 
advanced  stages  becomes  discolored,  bloody,  and  offensive.  On  the  other  hand,  the  dis- 
charge may  continue  for  many  months,  or  even  for  two  or  three  years,  unattended  by  any 
other  symptom,  and  yet  the  horse  be  decidedly  glandered.  The  glands  under  the  jaw  soon 
become  enlarged,  and  are  generally  observed  on  the  same  side  as  that  on  which  the  nostril 
is  affected  ;  the  swelling  at  first  may  be  somewhat  large  and  diffused,  but  this  subsides  in  a 
great  measure  and  leaves  one  or  two  glandular  enlargements,  which  become  closely  adhe- 
rent to  the  jaw-bone.  The  mucous  membrane  of  the  nose  becomes  of  a  dark-purplish  hue 
or  almost  of  a  leaden  color — never  the  faint  pink  blush  of  health,  or  the  intense  and  vivid 
red  of  usual  inflammation.  Spots  of  ulceration  will  probably  appear  on  the  membrane 
covering  the  cartilage  of  the  nose  ;  these  ulcers  are  of  a  circular  form,  deep,  and  with  abrupt 
and  prominent  edges,  and  become  larger  and  more  numerous,  obstructing  the  nasal  passages, 
and  causing  a  grating  or  choking  noise  in  breathing.  The  disease  extends  upward  into  the 
frontal  sinuses,  and  the  integument  of  the  forehead  becomes  thickened  and  swollen,  causing 
peculiar  tenderness.  The  absorbents  about  the  face  and  neck  now  become  implicated,  con- 
stituting farcy  ;  these  enlarge  and  soon  ulcerate.  The  absorbents  on  the  inside  of  the  thigh, 
and  then  the  deep  absorbents  of  both  hind  legs,  are  next  involved,  causing  the  parts  to  swell 
to  a  great  size,  and  to  become  stiff,  hot,  and  tender.  The  constitutional  symptoms  are  loss 
of  flesh,  impaired  appetite,  failing  strength,  and  more  or  less  urgent  cough  ;  the  belly  is 
tucked  up  ;  the  coat  is  unthrifty  and  readily  comes  off.  The  animal  soon  presents  one  mass 
of  putrefaction,  and  dies  exhausted." 

Man  is  exposed  to  infection  from  diseased  animals,  the  infectious 
matter  being  blown  out  of  the  nostrils  of  the  animal  into  the  eyes,  nose, 
or  mouth  of  the  individual,  or  the  disease  may  be  contracted  by  bathing 
in  water  in  which  brushes  or  harness  have  been  cleaned  after  having 
been  used  on  infected  animals.  Cavalrymen,  horseshoers,  hostlers, 
veterinaries,  and  butchers  are  most  exposed  to  infection. 

Course  and  Symptoms. — The  disease  may  run  a  course  in  man 
which  is  either  acute  or  chronic.  In  the  first  form  it  often  simulates 
rheumatism  or  typhoid  fever.  Beginning  with  malaise  and  rheumatic 
pains  in  different  parts  of  the  body,  an  elevated  temperature  soon 
develops,  and  with  it,  if  the  infection  atrium  is  upon  a  visible  part  of  the 
body,  nodules  appear  at  and  near  the  site  of  infection.  The  skin  may 
be  quite  generally  attacked  with  a  pustular  eruption  which  leaves 
ragged,  dirty  ulcers.  These  ulcers  may  spread  and  coalesce,  and 
phlegmonous  infiltrations  may  spread  away  from  them.  Lymphangitis 
and  lymphatic  adenopathy  are  often  seen.  The  primary  seat  of  disease 
may  be  in  the  upper  air-passages  or  even  in  the  bronchi,  but  this  local- 
ization is  not  so  common  in  man  as  in  the  horse.  The  secondary  foci 
of  the  disease,  due  to  the  transmission  and  localization  of  the  bacilli  by 
the  vascular  apparatus,  are  distributed  in  much  the  same  way  as  the 
secondary  foci  of  suppurative  inflammation,  to  which  the  individual 
lesions  bear  a  close  resemblance. 

While  the  acute  form  of  glanders  is  fatal  in  a  few  days  or  two  or 
three  weeks,  the  chronic  form  has  a  fatal  outcome  in  only  about  half 
the  cases,  and  then  only  after  from  two  months  to  one  or  more  years. 
In  the  chronic  form  of  the  disease  the  resemblance  of  the  pathological 
processes  is  in  favor  of  syphilis  and  tuberculosis.  These  secondary 
deposits  are  noted  not  only  in  the  internal  organs  but  in  the  muscles 
and  the  subcutaneous  tissues. 

The  morbid  anatomy,  according  to  Baumgarten,  is  that  of  a  dis- 
ease standing  midway  between  abscess  and  tuberculosis.     Says  Preisz : 


200  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

"The  first  beginning  of  the  nodular  formation  is  the  appearance  of  epithelioid  cells  with 
signs  of  karyokinesis,  exceptionally  also  with  several  nuclei.  These  epithelioid  cells  arise 
from  the  fixed  cells  of  the  connective  tissue,  of  the  vessels,  or  of  the  parenchyma  involved  ; 
from  the  border  of  the  nodule  there  begins  later  an  infiltration  by  wandering  leukocytes, 
which,  in  consequence  of  the  segmentation  and  breaking  up  of  their  nuclei,  are  more  nearly 
related  to  pus-corpuscles  than  are  the  leukocytes  of  tubercles  ;  finally  there  follows  softening 
and  breaking  down  of  the  nodule,  while  at  its  periphery  proceeds  the  process  described." 

The  diagnosis  of  glanders  in  the  well-marked  cases  occurring  in 
those  whose  occupations  are  suggestive  of  exposure  to  infection  is  by- 
no  means  difficult ;  but  in  the  acute  cases  affecting  persons  not  usually- 
associated  with  the  lower  animals,  especially  when  the  infection  atrium 
is  concealed,  and  when  the  symptoms  resemble  those  of  rheumatism 
or  of  septic  infection,  the  diagnosis  may  be  doubtful  or  even  erroneous. 
In  the  chronic  cases  in  which  localization  of  the  lesions  is  not  typical, 
doubt  or  confusion  may  again  occur. 

To  aid  in  diagnosis  we  have  several  valuable  signs,  some  of  which 
are  conclusive.  Of  these  are,  in  the  first  place,  the  discovery  and 
identification  of  the  Bacillus  mallei.  This  demonstration  is  proof  posi- 
tive of  the  disease.  Strauss  has  proposed  a  quicker  method  of  reaching 
a  conclusion — by  injecting  the  discharges  into  the  peritoneal  cavity  of 
male  guinea-pigs,  and  noting  the  swelling  of  the  testes  which  invariably 
occurs  within  a  few  hours.  Unfortunately  for  this  test,  the  swelling 
occurs  also  after  the  injection  of  certain  non-pathogenic  micro-organ- 
isms. J.  Koch  has  shown  that  it  is  not  necessary  to  inject  into  the 
peritoneal  cavity. 

When  the  tuberculin  test  for  tuberculosis  was  introduced,  efforts 
were  instituted  to  obtain  a  similar  test  for  glanders.  These  efforts  cul- 
minated successfully  in  the  discovery  of  mallein,  a  product  consisting 
of  the  toxins  of  the  glanders  bacterium  as  obtained  from  pure  cultures 
grown  on  various  artificial  media.  The  reagent  is  injected  hypoder- 
mically  in  quantities  corresponding  with  the  strength  of  the  preparation 
and  with  the  size  and  general  condition  of  the  subject.  When  a  suit- 
able dose  is  thus  administered  to  an  animal  or  a  man  affected  with 
glanders,  a  thermal  reaction  occurs  in  from  75  to  90  per  cent,  of  the 
cases.  The  rise  in  temperature  must  be,  in  horses,  not  less  than  2°  C. 
to  be  determinative.  The  value  of  the  mallein  test  is  considered  by 
Strube  to  be  quite  undetermined. 

Treatment  in  this  disease  also  becomes  largely  a  matter  of  pro- 
phylaxis, and  the  mallein  test  gives  us  abundant  aid  in  the  stamping 
out  of  the  contagion.  Since  horses  which  have  been  tested  with 
mallein  are  in  no  way  injured,  the  reagent  may  be  freely  applied  to  all 
the  horses  in  a  country  and  to  all  imported  animals,  all  the  infected 
animals  may  be  destroyed,  and  in  this  way  the  disease  may  be  almost 
or  quite  stamped  out.     Man  is  thus  best  protected. 

When  the  disease  is  once  contracted,  it  usually  proves  fatal  in  the 
acute  form.  No  adequate  treatment  has  yet  been  proposed,  although 
methods  by  the  use  of  the  serum  of  immunized  animals  have  been 
tried.  In  the  chronic  forms  of  the  disease,  in  which  the  death-rate  is 
not  so  high,  more  may  be  accomplished  by  surgical  treatment.  The 
ulcers  are  treated  antiseptically,  especial  pains  being  taken  to  destroy 
the  bacteria  in  the  discharges.  Abscesses  must  be  promptly  opened, 
if  possible  with  the  thermocautery,  in  order  to  prevent  further  infection 


A  CTINOM 1  'COSTS.  20 1 

by  way  of  the  lymphatic  system.     Of  course,  general  symptoms  will 
be  treated  according  to  ordinary  indications. 

ACTINOMYCOSIS. 

Actinomycosis  is  an  infectious  process  superinduced  in  man  and  in 
the  ox  by  the  micro-organism  known  as  actinomyces  or  ray-fungus.  In 
the  ox  the  disease  is  commonly  called  lumpy-jaw.  In  Germany  the 
fungus  is  called  Strahlenpilz,  and  the   disease   Strahlenpilz-krankheit. 

The  history  of  the  disease  as  a  recognized  entity  is  very  short. 
Although  Bollinger  was  the  first  to  prove  the  connection  of  the  ray- 
fungus  with  the  lumpy-jaw  of  cattle,  Langenbeck  (1845)  and  Lebert 
(1857)  had  pictured  the  fungus-granules  long  before.  Israel  in  1878 
described  "characteristic  mycoses"  in  man,  which  have  since  been 
recognized  as  cases  of  actinomycosis.  Ponfick  first  demonstrated  the 
actinomycotic  infection  in  such  cases  in  man,  and  established  its  pathol- 
ogy upon  a  sound  pathological  and  clinical  basis.  With  this  beginning, 
surgeons  in  all  parts  of  the  world  proceeded  to  a  careful  study  of  the 
disease  with  such  enthusiasm  that  in  1892  Illich  of  Vienna  was  able  to 
collect  421  cases  occurring  in  man.  Every  surgeon  of  experience  is 
now  familiar  with  the  malady,  and  while  actinomycosis  cannot  be  con- 
sidered a  common  disease,  it  is  far  from  being  rare.  The  experience 
of  recent  years  has  clearly  shown  that  in  the  region  of  the  jaw  many 
cases  of  so-called  chronic  alveolar  abscesses  are  undoubtedly  due  to 
actinomycotic  infection  ;  for  example,  at  the  Massachusetts  General 
Hospital,  Boston,  4  cases  were  discovered  in  one  week — an  example 
of  the  value  of  microscropic  examination  of  pus  in  all  suspected  cases. 

Minute  Anatomy. — The  bacteriology  of  actinomycosis  is  of  great 
interest,  especially  because  of  the  difficulties  encountered  in  artificially 
cultivating  and  classifying  the  micro-organism,  and  in  deciding  whether 
the  varying  forms  of  the  microbe  belong  to  one  or  more  species.  For 
a  discussion  of  this  part  of  the  subject  the  reader  is  referred  to  the 
chapter  on  Bacteriology.  We  may  say,  however,  that  the  production  of 
granules  is  characteristic  of  the  morbid  process.  These  granules  may 
be  sulphur-  or  grayish-yellow,  with  a  slightly  darker  center,  where  cal- 
careous deposit  may  occur,  and  are  composed  of  masses  of  interwoven 
filaments  of  the  actinomycetes,  surrounded  by  adherent  pus-corpuscles. 
The  presence  of  these  masses  in  the  tissues  gives  rise  to  much  prolifera- 
tive reaction  on  the  part  of  the  tissues,  which  is  expressed  in  the 
deposit  of  leukocytes,  the  multiplication  of  the  fixed  tissue-cells,  and 
the  formation  of  giant  cells.  The  kernel-like  mass  of  bacteria  is  thus 
soon  surrounded  by  active  granulation-tissue — the  usual  concomitant 
of  chronic  inflammation.  As  is  also  the  case  in  chronic  inflammation, 
this  newly-formed  connective  tissue  may  contract  at  a  later  time  and  cut 
short  the  activity  of  the  micro-organism.  But  a  single  nodule  of  this 
kind  is  not  likely  to  be  formed ;  many  such  masses  usually  lie  side  by 
side.  These,  by  coalescence,  produce  indurations  as  extensive  as  the 
diffusion  of  the  bacteria  permits.  These  masses  may  "  heal  out "  by 
penetration  of  the  connective  tissue  into  the  midst  of  actinomycetes. 
But,  on  the  other  hand,  degenerative  processes  in  the  center  may  occur, 
and  a  purulent  material  form,  which,  increasing  in  quantity  by  the  coal- 


202  INTERXATIOXAI.     Th  X  I  ' /.'<  "  >A'   OF  SFRCERY. 

escence  of  many  nodules,  may  be  forced  into  distant  tissues  by  the 
pressure  of  muscles,  etc.,  and  convey  the  disease  to  distant  structures. 
Fibrin  is  deposited  in  considerable  quantity  in  the  invaded  tissue. 

Should  this  process  occur  in  the  midst  of  bone-tissue,  the  osseous 
structure  will  be  destroyed  in  the  immediate  neighborhood  of  the 
disease,  while  the   bone  undergoes  hyperplasia  about  the   periphery. 

There  is  no  controversy  about  the  hyperplastic  activity  excited  by  the  ray-fungus  ;  but  all 
are  not  agreed  as  to  its  pyogenic  properties.  Israel  is  the  champion  of  the  pyogenic  theory. 
Bostroem,  with  whom  Eppinger  agrees,  believes  that  at  first  an  acute  inflammation  occurs, 
which  soon  becomes  a  chronic  process  of  a  reactive  proliferative  character,  and  as  a  result 
of  which  the  exudate  undergoes  disintegration.  Hobell,  whose  views  are  essentially  the 
same,  calls  attention  to  the  fact  that  actinomycosis  is  to  be  counted  as  one  of  the  forms  of 
pseudotuberculosis.  Aschoff  maintains  the  specific  pyogenic  power  of  the  organism,  and 
calls  especial  attention  to  the  metastases  of  the  disease,  with  which  pus  is  usually  associated, 
as  evidence  in  favor  of  this  view.  Of  course,  no  one  denies  that  pus  is  usually  associated 
with  all  forms  of  the  disease  as  it  occurs  in  man  ;  but  the  pus  is  generally  ascribed  to  a  mixed 
infection  with  other  micro-organisms. 

The  gross  pathological  anatomy  of  the  disease  is  everywhere 
associated  with  chronic  indurations,  with  softening  and  liquefaction,  and 
with  the  resulting  sinuses. 

About  the  head  and  neck,  which  are  favorite  sites  of  the  disease,  the  lower  jaw  and  cer- 
vical fascia  are  frequently  affected.  The  soft  parts  are  usually  thickened  and  indurated,  and 
here  and  there  soft  spots  occur,  which  eventually  break  down  and  result  in  sinuses,  discharg- 
ing a  thin  watery  pus,  in  which  are  usually  seen  the  small  sulphur-colored  granules.  The 
cervical  fascia  is  often  attacked  by  the  disease,  which  then  gives  the  neck  a  brawny  hardness 
that  may  become  very  extensive  in  area.  It  is  most  characteristic  of  this  affection  that  no 
glandular  enlargement  occurs  so  long  as  mixed  infection  is  absent.  Increase  in  size  of  ad- 
jacent lymphatics  is  therefore  definite  evidence  of  a  contamination  with  the  ordinary  pyo- 
genic organisms.  After  a  time  the  liquefaction-process  brings  about  the  formation  of  sinuses 
opening  upon  the  skin,  when  the  massive  enlargement  diminishes  somewhat  in  size.  In  the 
ox  the  tongue  is  often  affected,  and  attains  a  considerable  size  and  great  hardness.  In  the 
neck  the  skin  is  frequently  attacked,  the  induration  occurring  at  irregular  intervals,  throwing 
the  integument  into  folds  or  waves  of  irregular  enlargement. 

Although  the  ray-fungus  is  capable  of  producing  a  superficial  bronchitis  unassociated 
with  any  other  pulmonic  lesions,  the  lungs  are,  as  a  rule,  affected  with  a  well-marked  phthisis, 
which  usually  runs  a  course  much  like  that  of  tuberculosis.  In  the  abdomen  the  disease 
usually  takes  origin  in  the  appendix  or  cecum,  about  which  swellings  form,  which  may  be 
confused  with  carcinoma,  but  which  at  last  soften  with  the  discharge  of  pus.  Sinuses  open 
either  upon  the  skin  or  into  the  intestines  or  bladder. 

The  atria  of  infection,  the  symptoms,  and  the  course  of  actinomycosis  were  studied 
by  Israel  under  the  subdivisions:  (I)  Head  and  neck;  (2)  chest;  (3)  abdomen;  (4) 
brain  ;  and  (  5  )  the  skin.  Although  the  actinomycetes  have  not  been  studied  in  their  natural 
habitat  outside  the  body,  it  is  known  that  infection  usually  occurs  as  a  result  of  contact  with 
various  grains.  Infection  of  the  structures  of  the  head  and  neck  takes  entrance  through  the 
mouth  and  throat.  The  old  notion  that  those  engaged  in  the  care  of  actinomycotic  animals 
furnish  the  chief  contingent  of  cases  is  now  no  longer  tenable,  although  it  is  undisputed  that 
some  cases  of  the  disease  give  this  history.  The  majority  of  cases  are  infected  by  contact 
with  infected  grain.  A  most  striking  illustrative  instance  is  that  of  Bertha,  in  which  the 
disease  took  origin  in  a  wound  of  the  posterior  wall  of  the  pharynx.  In  the  wound  was 
found  a  grain  covered  with  actinomyces,  which  was  sticking  in  the  wound.  A  number  of 
patients  have  testified  that  they  were  in  the  habit  of  chewing  the  grains  or  the  straw  of 
wheat,  barley,  or  other  cereals.  In  the  Leipzig  Pathological  Institute  a  case  of  pulmonary 
actinomycosis  examined  post-mortem  was  carefully  studied  and  a  grain  found  in  the  lung- 
cavity.  It  was  supposed  to  have  been  aspirated  into  the  lung.  The  cases  of  intestinal 
actinomycosis  are  thought  to  be  caused  by  swallowed  bacteria. 

The  atrium  of  infection  in  the  faciocervical  form  of  the  disease  is  often  a  decayed  tooth, 
in  which  an  infected  grain  has  occasionally  been  found.  The  papillse  of  the  tongue  and 
the  follicles  of  the  tonsil  are  excellent  saccules  for  the  retention  of  the  infection-bearing 
body.  Infected  meat,  either  raw  or  imperfectly  cooked,  has  been  suspected  of  bearing  the 
disease.  The  well-recognized  cases  of  primary  cutaneous  actinomycosis  are  produced  by 
contact-infection  from  germ-laden  objects.  Actinomycotic  pus  is  thought  to  be  a  possible 
medium  of  infection.      Hence  the   surgeon   should  carefully  destroy  the  infected  dressings 


ACTIXOMYCOSIS. 


203 


and  o-uard  any  small   and  otherwise  insignificant  wounds  upon  the  skin  of  the  patient  or 
upon  his  own  hands. 

Although  the  infection  atrium  in  the  faciocervical  form  of  actinomycosis  is,  as  described, 
a  carious  tooth,  a  crypt  of  the  tonsils,  a  fold  of  mucous  membrane,  a  wound  or  an  ulcer, 
direct  evidence  'of  the  mode  of  entry  usually  disappears  early  in  the  course  of  the  disease. 
Indeed,  a  wound  or  ulcer  may  heal  entirely,  leaving  no  visible  trace,  while  actinomycosis  is 
going  on  in  neighboring  structures.  Once  the  disease  is  recognized  in  the  cheek  or  in  the 
connective  tissue  or  skin  of  the  neck,  a  tell-tale  band  of  scar-tissue  may  guide  the  diagnos- 
tician to  the  infection  atrium. 


Fig.  46. — Actinomycosis  of  the  cheek 
(Illich). 


FIG.  47. — Actinomycosis,  cervical 
type  (Illich). 


As  actinomycosis  is  essentially  a  chronic  process,  scar-formation 
may  obliterate  the  disease  at  some  points,  while  at  others  it  is  active. 
Hence  the  patient  may  come  to  the  surgeon  for  an  insignificant  indu- 
ration upon  the  jaw,  in  the  skin  of  the  cheek,  or  in  the  superficial  cer- 
vical fascia.  The  disease,  is  usually  painless,  and  mechanical  signs  are 
often  the  only  manifest  phenomena.  If  the  lower  jaw  is  attacked, 
ankylosis,  either  spasmodic  or  fibrous,  is  usually  present  in  varying 
degrees.  The  disease  in  the  skin,  at  first  showing  induration  only,  is 
soon  characterized  by  softening  at  the  center  of  the  nodular  mass  and 
reddening  of  the  skin.  Illich  compares  the  appearance  to  that  of  an 
inflamed  sebaceous  cyst.  If  the  fluctuating  center  is  incised,  the  char- 
acteristic granules  are  discovered  in  the  detritus  or  pus.  When  these 
infiltrations  occur  over  the  jaw,  they  are  usually  adherent  to  the  bone. 
As  secondary  mixed  infection  almost  always  takes  place  when  the  foci 
are  opened,  the  constitutional  disturbances  take  on  the  phenomena 
seen  in  pyogenic  infection.  The  disease  infiltrates  the  skin  progres- 
sively but  irregularly,  throwing  it  into  knobs  and  masses  which  are 
separated  from  one  another  by  depressions.  Usually  a  number  of 
sinuses  discharge  upon  the  skin  at  different  points. 

The  disease  thus  localized  may  terminate  in  recovery,  especially  if 


204  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

surgical  aid  is  extended  ;  but  it  may  end  fatally  by  extension  to  the 
meninges  of  the  brain  or  to  the  chest-cavity,  by  metastases  to  distant 
viscera,  or  by  secondary  septic  processes. 

Jurinka  reports  a  case  of  lingual  actinomycosis,  Koch  an  instance  of  a  parotid  localiza- 
tion, and  Marchand  two  examples  of  esophageal  actinomycosis.  In  one  of  these  cases  a 
small  perforation  of  the  esophagus  near  the  cardia  was  observed,  and  in  the  neighborhood 
was  an  extensive  sacculated  abscess  with  actinomycotic  pus. 

The  disease,  when  it  involves  the  face  and  neck,  is  of  slow  evolu- 
tion. Side  by  side  the  processes  of  destruction  and  proliferation  go  on, 
with  the  result  that  labyrinthine  sinuses,  opening  at  numerous  points 
on  the  skin,  burrow  in  the  superficial  fascia,  about  the  muscles  of  the 
neck,  and  often  along  the  course  of  the  great  vessels  or  along  the 
maxillary  bones. 

The  pulmonary  localization  of  the  disease,  thought  to  be  instituted 
by  the  inhalation  of  the  infectious  agent,  is  regarded  as  the  gravest 
form  of  actinomycosis. 

Illich,  after  an  exhaustive  study  of  the  literature  in  1892,  cited  only  two  cases  of  recovery 
in  pulmonary  actinomycosis.  The  high  mortality  he  thinks  due  to  the  inaccessibility  of  the 
disease,  but  more  especially  to  the  fact  that  it  spreads  so  extensively,  not  only  through  the 
lung-tissue  but  through  the  pleura,  the  peripleural  tissue,  and  into  the  neighboring  bones. 
Sinuses  opening  in  various  directions  are  likely  to  form,  and  surgical  procedures,  although 
properly  indicated,  are  likely  to  be  of  no  avail,  from  the  fact  that  all  foci  of  disease  cannot 
be  reached  and  extirpated.  The  disease  in  this  situation  simulates  tuberculosis  pulmonum 
very  closely  in  a  clinical  way  as  well  as  in  its  gross  anatomical  progress  (Illich).  Except 
where  the  disease — frequently  located  in  the  lower  lobe  of  the  lung — destroys  life  by  some 
pathological  catastrophe,  as  by  rupture  through  the  diaphragm,  it  is  likely  to  kill  by  ex- 
haustion and  septic  intoxication  due  to  mixed  infection. 

Abdominal  actinomycosis  is  thought  to  take  origin  in  ingested 
bacteria,  to  the  localization  of  which  no  part  of  the  gastro-intestinal 
tube  is  immune ;  but  those  parts  of  the  intestine  which  are  peristalti- 
cally  least  active  are  most  likely  to  be  affected.  This  is  especially  true 
of  the  cecum,  actinomycotic  inflammation  of  which  simulates  recurring 
attacks  of  appendicitis.  Abdominal  actinomycosis,  localized  in  struct- 
ures of  widely  varying  anatomical  peculiarities,  gives  rise  to  a  wide 
range  of  symptoms.  "  There  are,"  says  Illich,  "  cases  which  point  to 
disease  of  the  iliopsoas  muscle,  others  where  abdominal  pains,  some- 
times vague,  sometimes  localized,  or  cramps,  colic-like  attacks,  and 
vomiting  occur.  All  sorts  of  disturbances  of  defecation  have  been 
observed,  even  to  tenesmus,  with  discharge  of  mucus."  In  general, 
these  varying  symptoms  are  associated  with  the  occurrence  of  an  ab- 
dominal induration.  An  infiltration  may  extend  outward  from  within 
until  it  involves  the  skin,  and  a  diagnosis  is  made  upon  the  discovery 
of  the  actinomycetes  in  the  discharge.  The  pathogenic  organism  may 
be  discharged  by  the  rectum  or  the  bladder.  The  greatest  difficulty 
in  treatment  is  encountered  when  the  disease  involves  branches  of  the 
portal  vein,  since  actinomycotic  liver-abscesses  are  then  likely  to  make 
their  appearance  and  to  dominate  the  symptomatology  of  the  disease. 
Nevertheless,  a  number  of  cured  cases  of  the  abdominal  form  of  actin- 
omycosis are  now  on  record.  These  cases  are  sometimes  instances 
of  spontaneous  recovery ;  sometimes  are  due  to  a  combination  of 
medical  and  surgical  methods  of  treatment. 

Actinomycotic  disease  of  the  female  generative  organs   has  been 


ACTINOMYCOSIS.  205 

reported,  but  is  usually  secondary  to  disease  originating  in  other  parts 
of  the  abdomen.  Rarer  localizations  of  the  disease  are  the  middle  ear. 
the  larynx,  the  mammary  glands,  and  the  lacrimal  ducts.  An  interest- 
ing though  very  rare  manifestation  is  the  "paravertebral  phlegmon," 
of  which  the  exact  primary  origin  is  not  often  known.  Usually,  in 
connection  with  other  foci,  a  large  collection  of  pus  is  found  along 
the  front  and  sides  of  the  vertebral  column,  with  erosion  or  osteophytic 
enlargement  of  the  vertebrae.     Ankylosis  may  occur. 

Actinomycosis  is  capable  of  dissemination  through  the  system  in 
the  guise  of  pyemia.  Secondary  actinomycotic  foci  may  then  be  found 
in  the  most  widely  separated  viscera. 

Benda  reports  two  interesting  cases  of  metastatic  actinomycosis.  In 
the  first  case  a  disease  focus  upon  the  pericardium  of  the  right  heart 
broke  through  the  wall  of  the  coronary  vein  and  thus  obtained  access 
to  the  general  circulation.  In  the  second  case  the  disease  began  in 
the  vermiform  appendix  and  displayed  metastasis  in  the  liver. 

In  the  diagnosis  of  the  disease,  it  is  essential  to  bear  in  mind  the 
clinical  characteristics  already  portrayed ;  but  these  alone  are  not  suf- 
ficient to  distinguish  it  from  various  forms  of  the  other  infectious  granu- 
lomatous diseases — e.  g.y  tuberculosis,  syphilis,  etc.  The  cutaneous 
form  of  the  disease,  by  its  irregularly  nodular  indurations,  is  sugges- 
tively characterized ;  but  even  here  we  seek  other  signs.  The  crucial 
test  of  the  disease  is  fortunately  applicable  in  the  great  majority  of 
cases  of  the  disease — viz.,  the  discovery  of  the  micro-organism,  the 
peculiar  yellow  bodies  floating  in  the  pus.  These  masses  should  be 
examined  carefully  with  the  microscope,  since  granules  of  tubercular 
detritus  sometimes  simulate  them  in  gross  appearance.  The  nodule  is 
placed  on  a  glass  slide,  a  cover-slip  is  laid  over  it,  and  a  little  pressure 
applied  to  the  cover-slip  crushes  the  body.  The  radiating  clubbed 
filaments  may  then  be  recognized.  Further  investigation  has  shown 
that  clubbing  is  not  frequent  in  human  actinomycosis.  The  diagnosis, 
therefore,  should  rest  on  finding  filaments  which  branch  irregularly 
after  the  granules  have  been  teased  and  stained  by  Gram's  method. 
The  branching  distinguishes  the  actinomycetes  from  organisms  classed 
under  the  heading  of  leptothrix  buccalis. 

The  localized  forms  of  tuberculosis,  especially  in  the  skin,  are  best 
distinguished  from  actinomycosis  by  the  bacterioscopic  findings.  But 
the  fact  that  in  tuberculosis  the  regional  lymphatic  glands  are  often 
affected,  while  the  actinomyces  does  not  tend  to  disseminate  itself  in 
this  way,  should  aid  the  diagnostician. 

Carcinoma  of  the  tongue  is  situated  usually  near  the  base,  while 
actinomycosis  is  localized  near  the  tip.  Besides  this,  the  lancinating 
pain,  the  tenderness,  the  tendency  to  ulceration,  and  especially  the 
glandular  infiltration,  aid  in  the  distinction.  Syphilis  is  to  be  excluded 
by  the  collateral  evidences  of  the  disease  and  by  therapeutic  adjuvants. 
Actinomycosis  of  the  lungs  simulates  tuberculosis  so  closely  that  a 
distinction  without  microscopical  evidence  is  impossible.  Usually  the 
disease  attacks  the  lower  lobes  of  the  organs,  and  sinuses  leading  to 
the  skin  are  formed.  The  granules  discovered  in  the  pus  are  then  of 
decisive  value. 


206  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

It  is  equally  essential  in  the  diagnosis  of  the  abdominal  form  to  find 
the  actinomyces  in  the  pus  before  reaching  a  diagnosis  as  to  the  eause 
of  the  easily  discovered  induration  (Koranyi). 

Treatment. — Actinomycosis  in  cattle  is  to  a  considerable  degree 
amenable  to  internal  medication  by  potassium  iodid,  suggested  in  1885 
by  Thomassen  of  Utrecht  for  that  disease  when  localized  in  the  tongue. 
Eighty  cases  treated  by  him  were  all  cured.  Norgaard,  of  our  Bureau 
of  Animal  Industry,  first  applied  the  remedy  in  the  treatment  of  actino- 
mycosis of  the  jaw,  and  with  success.  Of  185  affected  animals  pur- 
chased by  the  Bureau  of  Animal  Industry,  131  were  cured  by  this 
drug.  "  In  most  of  these  cases,"  says  Dr.  Salmon,  "  after  treatment 
was  finished,  there  was  only  a  bunch  of  fibrous  tissue  to  show  where 
the  tumor  had  been."  To  these  animals  only  1^  to  2I  drams  (6  to 
10  gm.)  per  day  were  administered.  Iodism  appeared  in  the  course 
of  a  week  or  ten  days.  The  treatment  was  then  suspended  for  a 
few  days,  to  be  again  renewed  for  a  time.  Cures  have  often  been 
effected  in  two  weeks,  but  usually  treatment  is  required  for  twice  that 
period. 

In  man,  a  variety  of  remedies  were  vaunted  before  potassium  iodid 
gained  its  present  therapeutic  status.  Corrosive-sublimate  injections 
(Albert),  tuberculin  (Billroth),  carbolic  acid  and  glycerin  with  methyl 
violet  (Raffa),  and  silver-nitrate  sticks  introduced  into  the  sinuses 
(Kottnitz)  have  all  been  used,  according  to  Jurinka,  with  more  or  less 
success.  A  long  list  of  cases  treated,  and  for  the  most  part  cured,  by 
potassium  ioclid  is  cited  by  the  last-named  author.  The  dose  as  used 
by  Buzzi  and  Galli-Valerio  was  30  gr.  (2  gm.)  daily,  the  treatment 
being  continued  for  two  months.  Netter  began  with  a  dose  of  90  gr. 
(6  gm.)  daily,  then  diminished  to  15  gr.  (1  gm.),  which  was  continued 
until  in  one  month  a  cure  was  effected. 

The  experiments  of  Jurinka  upon  the  ray-fungus  in  vitro  do  not 
indicate  a  direct  bactericidal  action  on  the  part  of  the  drug ;  but  his 
finding  of  iodin  compounds  in  the  pus  of  patients  taking  the  drug 
proves  that  it  has  abundant  opportunity  to  reach  the  seat  of  disease. 
It  is  believed  that  it  acts  by  increasing  local  tissue-reaction.  Wolfler, 
in  whose  clinic  Jurinka  conducted  his  studies,  appends  a  note  to  the 
article  of  his  pupil,  in  which  he  further  commends  the  use  of  the  iodid 
and  adds  another  case  to  the  list  of  cures. 

We  must  admit  that  this  treatment  is  to  be  tried  persistently  in  all 
the  inaccessible  forms  of  the  disease,  and  tentatively  in  its  more  super- 
ficial manifestations  ;  but  adverse  reports  of  cases  in  which  the  drug 
was  tried  without  success  are  not  wanting.  The  failures  are  in  many 
cases  doubtless  due  to  the  extent  of  the  disease,  to  the  virulence  of 
the  infection,  to  a  secondary  mixed  infection,  or  to  an  inherent  lack 
of  resistance  on  the  part  of  the  individual  attacked.  It  is  possible  that 
there  are  several  varieties  of  the  cladothrix  grouped  under  the  title 
actinomyces,  which  have  different  degrees  of  invasive  activity  and  vary- 
ing powers  of  resistance  to  the  action  of  potassium  iodid  and  the 
granulation-tissue  proliferation  which  the  disease  excites.  These  ques- 
tions are  for  the  future  to  decide.  The  writer  observed  one  case  of 
the  faciocervical  type  in  which  the  drug  had  no  visible  effect. 


ACTINOMYCOSIS.  20"J 

G.,  farmer,  aet.  cir.  fifty-five  years,  toper,  noticed  a  swelling  under  the  left  inferior  max- 
illary bone  in  the  region  of  the  submaxillary  gland.  A  dentist  extracted  the  second  left 
lower  molar  tooth,  which  was  carious.  No  relief  followed  this  sacrifice.  The  swelling 
continued  to  increase  very  slowly  for  four  or  five  months,  when  the  patient  was  referred  to 
me  by  Dr.  Byron  Robinson.  At  that  time  the  swelling  was  about  the  size  of  a  hen's  egg 
and  was  adherent  to  the  inferior  maxilla,  over  which  it  was  immovable.  The  swelling  was 
hard,  diffuse,  and  indistinctly  outlined.  The  skin  over  the  mass  was  adherent,  especially 
over  the  most  prominent  part  of  the  tumor,  where  two  sinuses  opened.  The  skin  about 
these  openings  was  bluish  in  color  and  thin,  and  from  the  sinuses  was  discharged  a  thin 
serum-like  pus  which  contained,  here  and  there,  the  characteristic  granules  of  actinomycetes. 
When  the  patient  was  anesthetized  and  the  skin  opened  the  sinuses  were  seen  to  run  in 
various  directions,  honeycombing  the  superficial  fascia  and  at  times  perforating  it.  The  peri- 
osteum of  the  inferior  maxilla  was  attacked,  and  at  points  the  bone  was  denuded.  No 
lymphatic  glands  had  been  attacked.  The  operation  was  therefore  limited  to  a  thorough 
curetting  and  careful  excision  of  all  infected  tags  of  tissue  with  the  scissors.  Iodoform- 
gauze  packing  was  kept  up  carefully  until  the  wound  was  covered  with  granulations,  when 
the  patient  went  to  his  home  at  a  distance.  After  an  interval  of  about  three  months, 
the  patient  returned,  and  stated  that  the  disease  was  spreading.  It  was  found  to  have  ex- 
tended downward  along  the  superficial  fascia  for  about  two  inches,  with  numerous  pockets 
and  blind  sinuses  lined  with  flabby  granulations  secreting  a  thin  pus,  which  contained,  as 
before,  the  actinomyces-kernels.  The  parts  were  again  thoroughly  curetted,  and  diseased 
tissues  clipped  out  with  scissors.  The  patient  went  home,  and  in  about  five  months 
again  returned  with  a  recurrence.  This  time  it  was  decided  to  operate  radically.  With 
this  end  in  view,  the  tissues  were  thoroughly  opened  and  all  invaded  parts  exposed.  A 
dissection  was  made  as  carefully  as  possible,  almost  as  extensively  as  for  malignant  disease, 
the  incision  extending  almost  to  the  clavicle  below.  The  inferior  maxilla,  which  had  been 
curetted  at  the  second  operation,  was  at  this  time  found  so  deeply  invaded  by  the  actinomy- 
cotic caries  that  it  was  deemed  best  to  partially  resect  it.  The  resected  portion  included  all 
that  part  of  the  bone  extending  from  the  canine  tooth  to  the  articulation  of  the  left  side. 
Particular  care  was  taken  to  dissect  out  the  fascia  as  far  as  the  disease  could  be  detected. 
The  patient  bore  the  operation  well,  getting  out  of  bed  on  the  second  day  and  walking 
about  the  hospital.  His  wound  made  excellent  progress,  healing  through  a  considerable 
extent  by  first  intention.  A  sinus,  however,  remained,  and  eventually  began  discharging 
actinomyces  granules.  At  this  time  potassium  iodid  was  given  in  increasing  doses  for  several 
weeks  until  iodism  was  induced.  No  effect  on  the  disease  was  visible  at  any  time.  The 
patient  returned  to  his  home  and  began  a  systematic  course  of  drinking,  and  after  four  or 
five  months  died  of  a  basal   meningitis. 

Besides  the  fact  that  potassium  iodid  was  found  of  no  avail,  this  case  is  interesting 
because  of  the  great  resistance  of  the  infection   to  operative   procedures. 

Lieblein  has  gathered  reports  of  98  cases  in  which  potassium  iodid 
was  used.  In  62  cases  only  pharmacal  treatment  was  applied,  and  of 
these  42  were  healed,  9  being  apparently  permanently  cured.  In  the 
remaining  cases  the  drug  seemed  to  be  of  varying  value. 

We  know  that  the  disease  of  the  faciocervical  type  is  usually  amen- 
able to  the  simpler  surgical  procedures.  The  writer  had  proved  this 
in  the  case  of  a  young  laundryman  who  had  actinomycosis  of  the 
lower  jaw  near  the  angle  of  the  right  side.  The  origin  of  the  disease 
in  this  case  could  not  be  traced.  Simple  curetting  sufficed  to  effect  a 
permanent  cure. 

Dr.  L.  L.  MacArthur  reported  before  the  Chicago  Gynecological 
Society  a  case  of  mammary  actinomycosis  in  which  potassium  iodid 
was  of  no  avail,  and  in  which  amputation  had  eventually  to  be  resorted 
to. 

The  curious  case  is  now  under  the  observation  of  a  medical  friend 
of  the  writer,  of  a  woman  in  whom  a  number  of  sinuses  have  been 
discharging  actinomycotic  pus  for  more  than  ten  years.  Potassium 
iodid  causes  an  entire  cessation  of  the  discharge  of  actinomycotic 
granules  so  long  as  its  administration  is   continued ;   but  when  it  is 


208 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


omitted  for  a  few  days  the  granules  reappear.  Thus  the  drug  succeeds 
here  in  only  checking  the  disease,  but  does  not  cure  it. 

Jurinka  calls  attention  to  the  occasional  recurrence  of  the  disease 
after  a  superficial  healing  has  been  brought  about  by  the  iodid.  This 
recrudescence  may  necessitate  a  return  to  the  drug.  It  should  be 
mentioned  that  Wolfler  frequently  uses  applications  wet  with  potas- 
sium-iodid  solution  as  a  local  adjuvant  to  the  internal  treatment  with 
the  same  agent. 

We  should  begin  the  treatment  of  actinomycosis,  then,  in  all  acces- 
sible forms  of  the  disease  by  the  simpler  surgical  procedures,  regarding 
the  process  not  as  a  malignant  one,  but  as  a  malady  which  under 
favorable  conditions  can  be  overcome  by  the  tissues.  Potassium  iodid 
is  to  be  employed  as  an  adjuvant  in  these  cases,  and  as  an  independently 
curative  agent  in  the  inaccessible  forms  of  the  disease.  In  those  forms 
of  the  disease  in  which  the  process  has  gone  too  far  for  successful 
extirpation,  the  surgeon  should  open  all  accessible  collections  of  actino- 
mycotic pus,  split  such  fistulae  as  can  be  reached,  scraping  away  the 
detritus,  and,  while  continuing  daily  irrigations  with  suitable  antiseptics, 
administer  tonics  and  potassium  iodid. 


MADURA-FOOT. 

Madura-foot  is  a  disease  of  the  foot  observed  most  frequently,  though 
not  exclusively,  in  tropical  and  subtropical  countries.     Recognized  as  a 

distinct  disease  but  a  few 
years  ago,  and  occurring 
but  rarely  under  the  obser- 
vation of  competent  pa- 
thologists, madura-foot  is 
as  yet  an  imperfectly  stud- 
ied disease.  That  it  is 
caused  by  bacteria  and,  in 
all  probability,  by  the 
StrcptotJirix  madurce.  (Vin- 
cent), is  scarcely  to  be 
doubted.  This  micro-or- 
ganism, thought  by  many 
to  be  a  form  of  actino- 
myces,  is  doubtless  nearly 
related  to  that  cladothrix, 
but,  according  to  the  most 
recent  researches,  does  not 
seem  to  be  identical  with 
it.  We  again  refer  the 
reader  for  details  to  the 
chapter  on  Bacteriology. 


FlG.  48. — Madura-foot  or  mycetoma  (melanoid  vari- 
ety). Portion  of  amputated  part,  showing  general  ap- 
pearances of  the  lesions  on  a  section  extending  back- 
ward between  two  toes.  The  black  granules  are  seen 
embedded  in  atypical  granulation-tissue  (Beach  and 
Wright). 


The  morbid  anatomy  of  the  disease  is  clearly  elucidated  by  Paltauf  and  by  Vincent. 
In  the  soft  parts  of  a  specimen  examined  by  Paltauf  were  numerous  small  abscesses  con- 
taining pus  in  which  were  scattered  quantities  of  granules  of  pin's-head  size  and  smaller. 
By   such  abscesses   the   soft  parts  appeared  separated  from  the   carious  and   porotic  bone_ 


MADURA-FOOT. 


209 


Paltauf  called  attention  to  the  fact  that  in  actinomycosis  proliferation  and  osteophyte-forma- 
tion  are  observed. 

In  Vincent's  case,  quantities  of  ovoid  and  globular  whitish-yellow  granules  were  dis- 
charged. These  granules  were  com- 
posed of  mycelia  closely  interwoven. 
These  masses  of  mycelia  were  found  in 
the  tissues  at  the  centers  of  vascularized 
tubercle-like  nodules,  which  were  found 
grouped  together  very  frequently.  The 
skin  over  such  masses  was  atrophic. 
About  the  nodules  of  mycelia,  a  con- 
nective-tissue reaction  had  taken  place 
together  with  leukocytic  infiltration 
and  fibrinous  infiltration.  No  casea- 
tion changes  were  seen. 


Dr.  James  H.  Wright  de- 
scribes the  parts  removed  by 
Dr.  H.  H.  A.  Beach  from  the 
foot  of  an  Italian  woman  suf- 
fering from  this  disease,  as  fol- 
lows :  "  The  dissection  of  the 
amputated  part  showed  the  fol- 
lowing conditions  :  In  the  soft 
tissues  of  the  plantar  surface 
of  the  foot,  near  the  tarso- 
metatarsal articulations  and 
immediately  beneath  the  skin,  was  a  pigeon's-egg-sized  ovoid  tumor- 
mass,  sharply  defined  from  the  surrounding  tissue  by  a  faintly  indicated 


Fig.  49. — Same  case  as  Fig.  48,  showing  out- 
growth of  fungus  filaments  from  one  of  the  black 
granules.  Low  magnifying  power  (Beach  and 
Wright). 


S.«. ..  -  .•  .v    ,■-•-.    .-.•  *  i 


FlG.  50. — Same  case  as  Fig.  48.  Two 
bouillon  cultures  of  the  fungus,  showing  the 
powder-puff  appearance  of  the  growth.  In 
one  the  black  granule  is  seen  in  the  center  of 
the  mass  of  filaments  (Beach  and  Wright). 


'fir'-. 

„     t*  !k.'  ■•*»» 


'--■av.:V-V  .St-:^, 

Fig.  51. — Same  case  as  Fig.  48.  Section 
showing  a  granule  with  surrounding  giant 
cells  (Beach  and  Wright). 


connective-tissue  capsule.     This  mass  on  section  consisted  of  a  soft,  in 
places  gelatinous,  myxomatous-looking  tissue,  traversed  by  a  reticulum, 

14 


2IO  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

which  divided  it  into  ill-defined  small  areas,  and  in  these  areas  small, 
black,  irregular  granules  like  gunpowder  grains  were  present.  These 
grains  occurred  singly  and  in  groups.  The  tumor-mass  in  one  or  two 
places  also  presented  opaque  yellow  areas.  Two  other  similar  nodules 
of  small  size  were  also  found.  One  was  situated  in  the  soft  tissues  of 
the  dorsum  of  the  foot,  near  the  base  of  the  second  and  third  toes,  the 
other  in  the  soft  tissues  of  the  first  phalanx  of  the  second  toe.  The 
larger  of  these  nodules  was  of  about  the  size  of  a  pea.  The  bones 
were  not  involved." 

Symptoms. — The  disease  begins  either  upon  the  plantar  or  dorsal 
surface  of  the  foot,  and  gives  rise  to  a  painless  diffuse  swelling  of  its  soft 
coverings.  Hard  nodules  appear,  but  later  soften,  break  down,  and  dis- 
charge upon  the  skin  a  pus  containing  granules  of  the  mycelia  already 
mentioned.  In  certain  cases  attended  with  pain  these  swellings  remain 
hard. 

Two  forms  of  the  disease  are  clinically  distinguished — that  in  which 
the  granules  are  black,  and  that  in  which  they  are  white.  The  disease 
is  of  slow  evolution.  The  leg  involved  becomes  atrophied,  weak,  and 
useless.  Death  occurs  as  a  result  of  exhaustion,  or  of  complications 
which  are  only  indirectly  the  result  of  the  primary  disease. 

The  treatment  thus  far  employed  successfully  is  amputation. 

THE  BITES  OF  SERPENTS. 

The  wounds  inflicted  by  the  fangs  of  non-poisonous  serpents  give 
rise  to  no  more  disturbance,  local  or  systemic,  than  is  observed  from 
ordinary  wounds  inflicted  by  unclean  instruments.  The  bites  of  poison- 
ous serpents  are  more  or  less  dangerous  owing  to  the  injection  of  toxic 
substances  at  the  moment  the  injury  is  inflicted. 

Varieties  of  Serpents. — Of  the  1500  or  1800  species  of  snakes 
(ophidia),  there  are  five  kinds,  if  we  divide  them  according  to  their 
mode  of  life  and  habitat:  (1)  burrowing  snakes,  living  chiefly  under- 
ground, non-poisonous  ;  (2)  ground  snakes,  chiefly  non-poisonous  ;  (3) 
tree-snakes,  some  of  which  are  poisonous,  while  others  are  non-poison- 
ous ;  (4)  fresh-water  snakes,  almost  all  non-poisonous  ;  (5)  sea-snakes, 
which  do  not  leave  the  water  and  are  poisonous.  Serpents  exist  in 
greater  variety  and  numbers  as  we  approach  the  tropics. 

Of  the  venomous  serpents,  the  various  members  of  the  Naja  genus — 
the  cobras — are  much  dreaded  in  India  and  Africa.  The  mortality  from 
snake-bites  in  India  is  very  high.  In  the  province  of  Burdwan,  with  a 
population  of  six  millions,  more  than  one  thousand  deaths  occurred 
annually  for  nine  years.  Of  course,  there  are  other  venomous  serpents 
in  India,  which  are  partly  responsible  for  this  death-rate.  Tropical 
America  has  a  genus  of  especially  venomous  serpents  in  the  pit-vipers. 
Smaller  members  of  the  same  genus  are  found  in  the  temperate  zone 
of  North  America.  Of  these  there  are  two  species,  the  copper-head 
and  crater-moccasin.  The  rattle-snakes,  members  of  the  pit-viper 
family,  are  found  exclusively  in  America.  The  large  family  of  vipers, 
including  the  asps,  are  the  chief  venomous  serpents  of  Europe. 

All  venomous  serpents  possess  especially  differentiated  poison-fangs, 
which  are  situated  at  the  roof  of  the  mouth.     At  the  base  of  the  fangs 


THE   BITES   OF  SERPENTS.  211 

are  venom-elaborating  glands  with  sacs  for  containing  a  supply  of  the 
poison.  When  the  animal  strikes,  the  fangs  take  a  position  perpen- 
dicular to  the  edge  of  the  jaw,  the  tooth  penetrates  the  tissues  of  the 
victim,  and  at  that  moment  the  venom  is  injected  into  the  subciftaneous 
tissue  through  a  small  canal  in  the  poison-fang. 

Symptoms. — The  action  of  the  poison  is  thus  sudden  and  over- 
powering in  proportion  to  the  quantity  of  the  poison  and  its  deadly 
quality.  When  a  vein  is  penetrated,  the  effect  is  especially  sudden 
and  violent.  Serpents'  venom  brings  about  a  painful  swelling  at  the 
site  of  injury,  coagulation  of  blood,  and  consequent  thrombosis  of 
blood-vessels.  The  general  symptoms  are  collapse,  more  or  less 
complete,  convulsive  contractions,  and  vomiting.  Gangrene  or  anes- 
thesia is  occasionally  noted.  Death  usually  occurs  in  the  first 
forty-eight  hours.  If  the  patient  survives  this  period,  he  is  likely 
to  recover. 

The  local  treatment  of  poisoning  by  snake-bites,  when  the  injury 
occurs  upon  the  extremities,  consists  in  the  immediate  constriction  of 
the  limb  and  the  free  incision  of  the  skin  about  the  wound  to  allow  the 
escaping  blood  and  lymph  to  wash  out  the  venom.  This  may  be  aided 
by  sucking  the  wound,  a  procedure  which  is  not  dangerous  unless 
wounds  of  the  mouth  exist.  Injections  of  chemical  antidotes  may  be 
employed  if  they  are  at  hand  ;  but  it  is  useless  to  apply  them  if  evi- 
dences of  systemic  poisoning  indicate  that  the  dissemination  has  already 
begun.  Of  the  chemicals  employed,  potassium  permanganate  in  5  per 
cent,  solution  in  water  is  the  best  as  yet  known.  Two  to  three  drams 
of  the  solution  should  be  used  in  the  tissues  about  the  wound.  Other 
substances  are  in  use  for  injections — especially  sodium  hypochlorite, 
chromic  acid,  and  chlorin  water. 

The  systemic  treatment  by  the  use  of  antivenomous  scrum  has  been 
proposed  by  Calmette,  whose  success  in  the  production  of  immunity 
by  injecting  successively  larger  doses  of  poison  into  susceptible  animals 
is  well-known.  He  has  successfully  treated  poisoned  animals  which 
had  not  been  previously  immunized,  by  the  injection  of  the  serum  of 
protected  animals.  Fraser  has  dried  the  serum  of  immunized  ani- 
mals, and  finds  its  qualities  unimpaired  by  drying  and  storing.  Prac- 
tical applications  of  this  method  in  actual  cases  have  not  as  yet  been 
made  often  enough  to  give  definite  data  as  to  its  value. 

H.  P.  Keatinge l  reports  a  case  of  snake-bite  treated  by  antivenene 
serum.  A  child  was  bitten  on  the  forearm  by  an  Egyptian  cobra ;  she 
almost  instantly  became  unconscious.  The  village  barber  made  several 
incisions  on  the  arm  and  forearm.  When  brought  to  the  hospital  she 
was  cold  and  collapsed,  pulseless,  with  rambling  delirium.  It  was 
found  that  the  forearm  had  been  coated  with  Nile  mud,  which  is  a 
favorite  native  remedy ;  three  inches  below  the  bend  of  the  elbow  two 
distinct  holes  were  seen  passing  through  the  skin  and  corresponding 
to  the  fangs  of  the  serpent.  It  was  noted  that  the  pupillary  reflexes 
were  absent ;  the  pupils  were  moderately  dilated.  The  child  became 
comatose.  320TTI  (20  c.c.)  of  antivenene  serum  were  injected  under  the 
abdominal  skin.  In  four  hours  her  condition  was  distinctly  improved. 
160 TTt  (10  c.c.)  of  the  antivenene  serum  were  again  injected.     She  then 

1  Brit.  Med.  Jour.,  Jan.  2,  1897. 


212  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

slept  during  the  night,  and  the  next  morning  was  notably  better.     The 
serum  used  was  Calmette's  antivenene  serum. 

Strychnin,  ammonia,  and  alcohol  are  used  to  overcome  the  depres- 
sion caused  by  the  poison.  The  practice  of  inducing  intoxication  by 
the  use  of  large  quantities  of  whiskey  is  to  be  condemned. 

INSECT-BITES. 

The  bites  and  stings  of  many  insects  are  painful  and  annoying  only 
to  a  degree  corresponding  to  the  traumatism  inflicted.  In  the  case  of 
mosquitoes,  bees,  hornets,  tarantulas,  ordinary  spiders,  etc.,  poisons  are 
usually  introduced  into  the  wounds  inflicted,  and  cause  a  dispropor- 
tionate wound-reaction. 

Symptoms. — Within  a  few  minutes,  in  the  case  of  persons  sus- 
ceptible to  the  action  of  these  poisons,  swelling  takes  place  about  the 
point  of  injury,  and  hours  may  pass  before  the  edema  disappears. 
Itching  and  pain  accompany  the  redness  and  swelling.  If  loose  tis- 
sues are  attacked — as  about  the  eyelids — the  swelling  may  be  very 
distressing  in  its  consequences. 

It  is  only  when  the  poison'  is  thrown  directly  into  the  circulation 
that  serious  symptoms  follow  a  single  bite  or  sting.  Some  individuals 
are  especially  susceptible  to  this  form  of  poisoning,  and  are  rendered 
ill  by  it ;  while  others  are  not  troubled  even  by  numerous  bites. 
Managers  of  apiaries  are  said  to  acquire  a  well-marked  immunity  to 
the  poison  of  bees,  so  that  the  wounds  cause  them  annoyance  solely 
on  account  of  the  traumatism  produced. 

The  infliction  of  a  large  number  of  bites  or  stings  may  have  serious 
consequences  owing  to  the  quantity  of  poison  introduced ;  indeed, 
deaths  are  known  to  have  occurred  in  not  a  few  instances  from  this 
cause. 

The  nature  of  the  poisons  which  are  introduced  has  been  but  little 
studied.  It  is  supposed,  however,  that,  like  the  poisons  of  the  venom- 
ous serpents,  they  are  of  the  nature  of  leukomains. 

The  treatment  of  insect-bites  and  stings  is  by  the  application  of 
cooling  lotions  and  the  local  use  of  various  drugs  supposed  to  have  a 
more  direct  action  on  the  poison  and  on  its  pathological  consequences. 
Of  these,  ammonia  and  some  of  its  compounds  are  very  frequently  used. 
Ottinger  recommends  ichthyol,  either  pure  or  mixed  with  an  equal 
quantity  of  lanolin.  Camphor,  camphor-chloral,  and  menthol  are 
recommended. 


CHAPTER    IX. 
GANGRENE. 

Classification. — The  Greek  word  ydyypacva,  from  ypdeiv,  to 
gnaw,  meant  an  eating  sore,  such  as  phagedena  and  hospital  gangrene, 
but  is  now  a  general  term  for  the  partial  death  of  the  tissues,  espec- 
ially of  the  extremities.  Hydxelo-,  from  aifd^ecv,  signified  the  process 
ending  in  the  death  of  the  tissue,  hence  "  sphacelation  "  is  equivalent  to 
"mortification."  "Sloughing"  is  the  process  of  separation  and  cast- 
ing off  the  dead  tissue  from  the  living,  as  a  serpent  sheds  its  epidermis. 

The  immediate  cause  of  the  death  of  a  part  is  the  failure,  whether 
partial  or  complete,  of  the  circulation  through  the  part.  The  com- 
plete arrest  of  the  circulation  through  the  skin,  bone,  or  connective 
tissue  for  twelve  hours  certainly  causes  death,  and  a  much  shorter 
period  is  sufficient  for  softer  parts. 

It  is  impossible  to  distinguish  sharply  the  different  forms  of  gan- 
grene, since  there  is  so  much  interaction  of  the  various  causes.  The 
division  into  dry  and  moist  gangrene  is  largely  accidental.  Traumatic 
gangrene  cannot  be  separated  from  the  idiopathic  form  due  to  disease 
in  those  cases  where  the  traumatism  consists  in  inoculating  septic 
organisms,  or  where  a  small  cut  on  the  toe  is  the  exciting  cause  of 
gangrene  owing  to  the  diseased  condition  of  the  patient's  vessels. 

The  term  Raynaud' 's  disease  is  often  used  so  as  to  include  various  kinds  of  gangrene. 
Raynaud  emphasized  symmetry  and  paroxysms  in  cases  where  arterial  obstruction  is  absent. 
But  the  term  Raynaud's  gangrene  is  sometimes  applied  to  any  case  of  symmetrical  gan- 
grene, although  the  symmetry  may  result  from  heart  failure,  thrombosis,  or  symmetrical 
arterial  disease.  Paroxysmal  symptoms  frequently  usher  in  gangrene  due  to  arterial  disease. 
Even  amongst  the  cases  to  which  the  name  of  Raynaud  is  more  properly  attached,  there  is 
one  set  in  which  anemia  and  cardiac  weakness  are  also  present,  and  another  class  charac- 
terized by  thickened  tortuous  arteries  with  high  pulse  tension  in  comparatively  young 
patients.      Such  cases  may  be  asymmetrical,  confined  to  one  limb,  and  show  no  paroxysms. 

The  term  "spontaneous''  as  applied  to  cases  of  gangrene  becomes  more  and  more 
unsuitable  as  the  pathology  of  gangrene  is  better  known. 

The  predominating  factor  in  gangrene  is  the  partial  or  complete 
failure  of  the  blood-flow,  and  therefore  in  this  article  the  subject  of 
gangrene  is  considered  according  to  the  most  prominent  and  imme- 
diate cause  of  the  circulatory  failure — viz.,  (i)  the  impairment  of  the 
general  circulation,  (2)  obstruction  of  the  main  arteries  and  veins, 
(3)  obstruction  of  the  smaller  arteries,  (4)  spasm  of  the  arterioles, 
(5)  obstruction  of  the  capillaries  and  venules. 

There  are  two  practical  considerations  which  control  the  description 
of  gangrene  here  given  ;  first,  the  prevention  of  the  various  forms  of 
gangrene,  and  second,  the  opportune  removal  of  the  dead  part,  so  as 
to  bring  about  healing  and  save  life. 

Mortification. — When  a  part  dies  as  a  whole  and  at  once,  the 
dead  part  undergoes  the  same  changes  as  does  the  body  after  death. 

213 


214  INTERNATIONAL    TEXT-BOOK    OF  SURGERY. 

The  skin  becomes  absolutely  cold,  white,  and  sometimes  marbled  by 
the  stagnant  blood  in  the  superficial  veins.  Rigor  mortis  quickly  sets 
in,  and  passes  off  with  the  onset  of  putrefaction.  On  cutting  into  the 
part,  the  only  blood  which  escapes  comes  from  the  veins ;  the  prox- 
imal ends  of  the  cut  arteries  are  quite  empty,  and  muscle-serum  oozes 
from  the  rigid  muscles.  Swarms  of  bacteria  soon  appear,  the  subse- 
quent putrefactive  changes  being  dependent  upon  the  amount  of  heat 
and  moisture  present.  When  the  limb  is  affected  above  the  wrist  or 
ankle,  and  venous  stagnation  has  preceded  the  absolute  arrest  of  the 
circulation,  the  limb  undergoes  "moist  gangrene" — i.  e.,  those  putre- 
factive changes  which  take  place  in  a  moist  and  warm  atmosphere. 
The  hemoglobin  diffuses  out  and  stains  the  deeper  part  of  the  skin  a 
dusky  brown  which  becomes  more  and  more  green.  A  distinctly  foul 
odor  is  perceived.  The  epidermis  is  easily  detached,  showing  a  green 
dermis  beneath.  Then  patches  of  green  skin  separate  and  come  away 
with  the  least  touch,  exposing  the  muscles  which  are  seen  to  be  falling 
apart  and  liquefying.  On  the  contrary,  when  the  arterial  circulation 
has  been  arrested  without  impeding  the  venous  return,  the  part  is  com- 
paratively free  from  moisture,  and  in  a  dry  atmosphere  undergoes  "  dry 
gangrene."  This  is  especially  seen  in  the  hands,  feet,  tips  of  the  ears 
and  nose.  The  tissues  shrivel  up  and  become  hard,  like  a  well-pre- 
served mummy,  in  which  the  structure  of  all  the  harder  tissues  remains 
unaltered.  The  cold,  dead-white  or  marbled  limb  begins  to  shrink; 
the  skin  becomes  hard  and  horn-like,  and  rings  when  struck.  The 
color  changes  to  a  dark  olive-brown,  then  becomes  blackish.  There 
is  little  more  than  a  musty  odor.  When  the  muscles  are  cut  into, 
some  may  be  found  still  containing  moisture  and  of  a  uniform  red ; 
later  on,  these  likewise  shrivel  up,  leaving  horny,  brownish-black 
material.  The  action  of  putrefactive  organisms  is  prevented  by  the 
lack  of  moisture. 

Sloughing  is  the  separation  of  the  dead  part  from  the  living.  In 
this  condition  a  line  of  demarcation  gradually  appears  at  the  margin 
of  the  living  skin  where  it  borders  on  the  dead.  At  first,  this  line  is 
ill  defined — in  dry  gangrene  on  account  of  the  feeble  circulation  in  the 
living,  and  the  slight  amount  of  putrefaction  in  the  dead,  tissue  ;  in 
moist  gangrene  because  the  line  is  irregular,  not  forming  a  circle 
round  the  limb,  but  varying  according  to  whether  cutaneous  arteries 
are  obstructed  or  patent. 

In  the  dead  part  there  is  an  absence  of  sensation  ;  in  the  living  there 
is  hyperesthesia,  increasing  to  pain  in  the  region  of  the  line  of  sepa- 
ration. A  dead  part  shows  no  capillary  circulation  and  is  absolutely 
cold ;  in  the  living  there  is  at  least  some  circulation,  so  that  the  skin 
becomes  paler  on  pressure  with  the  finger  and  recovers  some  color  on 
releasing  the  pressure.  When  a  part  is  swollen  and  pits  on  pressure, 
if  the  pitting  remains  after  relaxing  the  pressure,  the  circulation  is  in- 
sufficient and  gangrene  is  threatened;  if  the  pitting  disappears  on 
taking  off  the  finger-pressure,  a  blood-supply  enough  to  maintain  the 
life  of  the  tissues  is  indicated.  The  dead  part  remains  cold ;  the  living 
increases  in  warmth,  especially  in  the  region  of  the  line  of  demarcation, 
until  a  zone  of  inflammatory  redness  becomes  apparent.  When  gan- 
grene supervenes  on  acute  inflammation,  the  redness  of  the  dying  and 


GANGRENE.  2  I  5 

dead  tissue  grows  more  dusky  and  does  not  alter  on  pressure,  the 
color  becomes  bluish,  then  greenish,  and  a  fetid  odor  is  apparent.  The 
still  living  tissue  remains  brightly  red,  the  redness  diminishing  on  press- 
ure, but  returning  immediately  the  pressure  is  taken  off.  The  bright 
inflammatory  zone  in  the  living  part  fades  away  into  the  healthy  skin 
above.  The  "line  of  demarcation"  appears  at  the  lower  margin  of 
the  living  tissue,  where  a  line  of  pustules  forms  beneath  a  layer  of 
whitish  epidermis.  On  raising  the  epidermis  and  washing  away  the 
pus,  a  gutter-like  ulcer  is  seen,  which  extends  through  the  skin.  The 
ulcer  encircles  the  limb  and  becomes  gradually  deeper. 

In  dry  gangrene  the  muscles  are  usually  better  supplied  with  blood 
than  the  skin,  and  the  bone  better  than  either,  so  that  the  typical  result 
in  dry  gangrene  after  spontaneous  separation  is  a  conical  stump  with 
the  bone  projecting  beyond  the  soft  parts.  In  moist  gangrene  muscles 
may  slough  beneath  intact  skin,  and  the  shaft  of  a  bone  may  undergo 
necrosis  up  to  the  joint  above. 

Beneath  the  skin,  vascularity  is  the  indicator  of  the  living  tissue.  The 
living  bleeds  when  cut  into ;  the  dead  does  not,  owing  to  septic  throm- 
bosis. The  living  muscle  and  bone  increase  in  vascularity  owing  to 
inflammation  and  ulceration  excited  by  contact  with  the  dead.  Dead 
muscle  breaks  down  into  thin,  foul,  greenish  pus,  the  connective-tissue 
sheaths,  fascia,  and  tendon  form  yellowish  or  grayish-white  tough 
sloughs,  the  bone  becomes  white  or  greenish-white  and  rings  when 
struck. 

The  Effect  of  the  Dying  and  the  Dead  Tissues  on  the  Body  gener= 
ally. — Putrefaction  is  a  process  of  oxidation  ending  in  the  formation 
of  carbonic  acid,  water,  and  free  nitrogen.  But  abundance  of  oxygen 
is  required  to  carry  out  this  process  rapidly.  Wherever  the  oxygen 
from  the  atmosphere  cannot  freely  reach,  the  oxidation  is  relatively 
slowrer  and  the  number  and  persistence  of  intermediary  products  rela- 
tively greater.  These  act  locally  on  the  living  tissues  and  set  up  sup- 
puration in  them,  from  which  septic  products  enter  the  circulation. 
Proteids  form  poisons  containing  nitrogen,  carbon,  and  hydrogen, 
allied  to  the  poisonous  alkaloids  found  in  plants  and  to  the  precursors 
of  urea  and  uric  acid.  The  sulphur  forms  sulphuretted  hydrogen. 
Non-nitrogenous  carbohydrates  and  fats  produce  irritating  acids,  lactic 
acid,  and  other  fatty  acids,  also  poisonous  gases,  such  as  marsh  gas.  In 
the  presence  of  abundance  of  oxygen,  such  substances  are  rendered 
harmless  by  oxidation.  Putrefaction  is  partly  or  wholly  stopped  by 
desiccation,  the  albumins  drying  up  into  a  horny  substance. 

The  body  is  directly  affected  by  the  actual  loss  of  the  dead  part 
when  a  limb  is  suddenly  crushed  or  the  main  artery  obstructed  by  an 
embolus;  shock  is  then  produced  just  as  if  the  limb  had  been  ampu- 
tated. 

Absorption  of  the  poisonous  products  from  the  dead  part  ceases 
when  the  circulation  is  arrested,  and  so  this  is  only  of  importance  in 
partial  and  spreading  gangrene.  In  dry  gangrene  there  is  very  little 
absorption,  even  although  the  circulation  has  not  quite  stopped,  because 
the  return  circulation  is  so  very  small.  The  drier,  therefore,  the  dead 
tissues  and  the  more  freely  they  are  exposed  to  the  atmosphere,  the  less 
is  the  irritation  of  the  living  tissues.     The  more  moist  the  gangrene 


2l6  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

and  the  less  the  oxygen  penetrates  to  the  decomposing  tissues,  the 
more  dangerous  is  the  poisonous  influence  upon  the  living.  The  local 
reaction  of  the  living  tissues  is  then  marked  by  profuse  ulceration  and 
suppuration,  and  septic  absorption  is  indicated  by  the  general  con- 
dition of  the  patient. 

Partial  and  spreading  gangrene  causes  much  more  absorption  of 
septic  matter  relative  to  the  extent  of  the  gangrene.  In  partial  gan- 
grene the  return  circulation  brings  back  substances  from  the  dying 
tissue,  and  when  there  are  scattered  patches  of  gangrene  the  area  of 
contact  with  the  living  tissues  is  much  greater.  In  spreading  gangrene 
previously  healthy  tissue  is  being  continuously  invaded,  and  fresh  ab- 
sorption is  originated  at  each  stage.  Moreover,  the  removal  of  the 
dead  part  is  apt  to  be  delayed  or  to  be  incomplete,  owing  to  the  uncer- 
tainty as  to  the  line  of  demarcation. 

Ischemic  Degeneration. — Whenever  the  blood-supply  becomes  in- 
sufficient, the  cells  of  the  skin  and  muscle,  as  well  as  the  blood-cor- 
puscles, exhibit  signs  of  degeneration.  The  change  commences  in  the 
nucleus ;  the  chromatin  filaments  break  up  into  lumps,  granules,  or 
refracting  bodies,  and  no  longer  stain  with  nuclear  dyes.  The  nucleus 
is  dissolved  in  the  protoplasm,  which  then  liquefies,  so  that  the  whole 
cell  is  broken  down  and  disappears.  The  striae  fade  from  muscle-fibers, 
leaving  a  homogeneous  semi-fluid  substance,  which  ruptures  the  hyalin 
sheath.  The  hemoglobin  of  the  red  corpuscles  is  first  reduced,  then 
rendered  iron-free,  and  so   comes  to   resemble  the  bile-pigments. 

An  insufficient  blood-supply  may  cause  a  limb  to  become  weak  or 
completely  paralyzed  and  atrophied.  If  the  failure  of  the  blood-supply 
stops  short  of  causing  gangrene,  ischemic  rigidity  and  paralysis  are 
followed  by  an  interstitial  myositis  and  permanent  contracture.  A 
limb,  after  becoming  insensitive  and  cold,  may  commence  to  shed 
its  epidermis,  and  yet  stop  short  of  gangrene.  If  the  heart's  force,  is 
increased  or  the  collateral  circulation  is  established,  warmth  and 
sensation  return,  and  there  is  simply  desquamation. 

L  GANGRENE  FROM  IMPAIRMENT  OF  THE  GENERAL  CIRCULATION. 

Fatty  degeneration  with  exhaustion  of  the  heart-muscle  is  a  great 
predisposing  cause  of  gangrene,  yet,  as  long  as  the  circulation  is  equally 
distributed,  no  gangrene  need  actually  start.  When,  however,  an 
artery  is  blocked  by  embolism  or  thrombosis,  the  collateral  circulation 
is  insufficient  to  maintain  the  life  of  the  tissues.  Embolism  is  the 
result  of  endocarditis  ;  if  it  is  acute,  the  emboli  are  septic,  and  the 
danger  of  moist  gangrene  the  more  likely.  Chronic  endocarditis  gives 
rise  to  embolism  either  by  the  formation  of  fibrin  or  by  the  detachment 
of  a  vegetation  from  a  valve.  A  slow  and  feeble  circulation  consequent 
on  cardiac  weakness  tends  to  produce  thrombi  in  the  heart,  from  which 
emboli  may  be  detached,  and  also  thrombosis  in  the  arteries  of  the 
limbs,  in  which  the  circulation  is  especially  feeble.  A  patent  septum 
of  the  heart,  producing  cyanosis,  predisposes  to  gangrene,  owing  to  the 
imperfect  aeration  of  the  blood.  The  morbus  caeruleus  is  distinguished 
by  being  general,  including  the  lips,  and  the  color  is  blue  as  com- 
pared   with    the    local    dusky    red,    tending    to    green,    of    gangrene. 


GANGRENE  FROM  BLOOD-VASCULAR    OBSTRUCTION.  2\J 

Cyanosis  from  bronchitis,  emphysema,  etc.,  has  the  same  influence.  A 
diminution  in  blood-pressure  also  predisposes  to  gangrene,  so  that  ex- 
haustion, want  of  food,  and  loss  of  blood  render  the  wounded  lying 
on  the  ground  after  a  battle  liable  to  gangrene,  although  the  tempera- 
ture does  not  fall  below  freezing  point.  Acute  diarrhea  and  cholera 
tend  to  cause  gangrene  by  weakening  the  circulation  and  producing 
thrombosis.  The  acute  specific  fevers  and  other  exhausting  diseases 
act  in  a  similar  manner. 

In  children  multiple  gangrenous  patches  may  appear  on  the  skin 
of  the  limbs  and  abdomen  a  few  hours  or  days  before  death.  Nothing 
is  found  post  mortem  except  some  soft  thrombi  in  the  main  vessels 
of  the  limb  affected.  Sometimes  such  cases  have  been  attributed 
to  abnormalities  of  the  blood-vessels  (Solly  r),  but  the  apparent  small 
size  of  the  main  arteries  may  well  be  secondary  to  the  previous 
disease. 

The  symmetry  often  met  with  is  vascular  in  origin,  and  is  therefore 
distinct  from  the  symmetry  noted  in  Raynaud's  disease,  which  is  due 
to  the  distribution  of  the  nerves. 

Treatment. — Gangrene  arising  from  a  failure  of  the  general  circu- 
lation can  hardly  be  foreseen,  and  in  most  cases  the  patient  is  too  ill 
to  complain  of  any  premonitory  symptoms.  Careful  watching  and 
examination  of  the  patient  lead  to  the  discovery  that  the  limbs  are 
becoming  cold  and  losing  sensation,  or  that  dusky  red,  indurated 
patches  are  appearing  on  the  skin.  The  occurrence  of  gangrene  is 
warded  off  by  improving  the  force  of  the  heart,  replacing  lost  fluid 
by  saline  infusions  or  rectal  enemata,  wrapping  up  cold  limbs,  and 
avoiding  pressure  and  all  causes  of  irritation.  Surgical  measures  are 
necessarily  dependent  upon  the  condition  of  the  patient,  which  is  often 
beyond  hope.  If  amputation  is  done,  it  must  be  at  the  level  at  which 
the  main  artery  can  still  be  felt  patent,  not  below.  Thrombosed  and 
gangrenous  patches  of  skin  should  be  at  once  incised  and  iodoform 
gauze  slipped  beneath.  This  prevents  further  absorption  from  the 
slough,  which  is  later  on  removed. 


H.  GANGRENE  DUE   TO   THE  OBSTRUCTION  OF  A  MAIN  ARTERY 

OR  VEIN. 

If  a  main  artery  is  blocked,  and  the  collateral  circulation  is  not 
quickly  established,  gangrene  must  ensue.  The  anatomical  conditions 
may  be  favorable  for  a  collateral  circulation,  or  they  may  be  the  re- 
verse. Anastomosis  is  so  complete  in  the  case  of  the  branches  of  the 
external  carotid  that  the  cut  distal  ends  pulsate.  On  the  other  hand, 
there  is  no  anastomosis  between  the  branches  of  the  pulmonary  artery 
or  of  the  superior  mesenteric,  and  hence  gangrene  inevitably  follows 
on  obstruction  of  these  vessels.  The  testis  sloughs  when  both  sper- 
matic and  deferential  arteries  are  cut  off.  There  is  a  sufficient  anasto- 
mosis in  the  limbs  to  maintain  life  after  the  obstruction  of  the  main 
artery,  provided  always  that  the  smaller  vessels  are  unobstructed. 
Anatomically  the  most  unfavorable  anastomoses  are  those  rendered 
necessary    when    the    common    femoral    and    the    axillary   artery   are 

1  Med.-Chir.   Trans.,  1839,  p.  253  ;   1840,  p.  236. 


2l8  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

blocked.  When  the  common  femoral  is  obstructed,  the  blood,  in 
order  to  reach  the  foot,  has  to  pass  through  a  double  set  of  capil- 
laries— from  those  of  the  branches  of  the  external  and  internal  iliacs 
into  the  branches  of  the  profunda  femoris,  and  thence  into  the  branches 
of  the  superficial  femoral  and  popliteal — before  it  can  reach  the  leg. 
The  greater  the  anatomical  difficulties  in  the  way  of  developing  the 
collateral  circulation,  the  greater  is  the  need  of  a  good  general  circu- 
lation; and,  conversely,  there  is  greater  danger  of  gangrene  when  the 
circulation  is  weak. 

The  chief  obstacle  to  the  development  of  a  collateral  circulation  is 
the  simultaneous  obstruction  of  the  smaller  arteries  and  arterioles. 
This  may  take  place  from  many  small  emboli,  from  thrombosis,  or 
from  a  gradual  narrowing  of  the  lumen  owing  to  disease,  and  also  from 
outside  pressure.  The  collateral  circulation  takes  some  little  time  to 
establish  itself;  hence  a  sudden  and  complete  obstruction  to  a  main 
artery  favors  the  immediate  onset  of  gangrene,  whilst  the  slow  devel- 
opment of  an  obstruction  gives  the  collateral  vessels  time  to  dilate. 

Obstruction  to  the  return  of  venous  blood  predisposes  to  gangrene 
whenever  there  is  at  the  same  time  septic  thrombosis.  The  common 
femoral  and  the  subclavian  vein  return  most  of  the  venous  blood,  but 
they  may  become  obstructed  without  causing  more  than  venous  con- 
gestion, unless  there  be,  in  addition,  septic  inflammation,  in  which  case 
moist  gangrene  will  quickly  set  in. 

A  wound  of  a  large  artery  is  liable  to  be  followed  by  gangrene, 
owing  to  the  general  circulation  being  weakened  by  loss  of  blood. 
Both  wounds  and  ligation  in  continuity  were  formerly  liable  to  be 
followed  by  gangrene,  owing  to  the  septic  inflammation  and  throm- 
bosis which  spread  immediately  from  the  wound  and  obstructed  the 
collateral  circulation,  or  later,  after  loss  of  blood  by  secondary  hemor- 
rhage. As  an  aneurysm  develops  on  an  artery,  it  presents  a  gradually 
increasing  obstruction  to  the  blood-flow ;  but  should  the  aneurysm 
become  suddenly  diffuse,  the  collateral  circulation  already  developed 
will  be  thereby  obstructed,  and  so  gangrene  will  be  likely  to  follow  a 
ligation  in  continuity,  although  the  operation  be  completely  aseptic. 

Main  arteries  become  obstructed  by  emboli  detached  from  the  heart, 
or  by  thrombosis  due  to  a  feeble  circulation  or  to  disease  of  the  arte- 
rial wall.  The  disease  of  the  arterial  wall  is  occasionally  acute  arte- 
ritis resembling  acute  endocarditis ;  but  it  is  much  more  commonly 
atheroma,  or  arteritis  obliterans.  The  main  arteries  are  further  ob- 
structed by  external  compression,  tumors,  foreign  bodies,  bullets,  and 
unreduced  fractures  and  dislocations,  and  if  at  the  same  time  the  col- 
lateral circulation  be  partly  hindered,  gangrene  is  the  more  likely  to 
follow. 

The  circulation  through  the  main  artery,  as  well  as  the  collateral 
circulation,  is  obstructed  in  utcro  by  bands  formed  in  the  fetal  mem- 
branes. Both  lower  extremities  have  spontaneously  separated  at  the 
hip-joint  (Duer1).  In  Maddin's2  case  amputation  at  the  junction  of 
the  upper  and  middle  thirds  of  the  thigh  was  successfully  carried  out 
on  the  third  day  after  birth. 

1  Brit.  Med.  Jour.,  1897,  vol.  ii.,  p.  1179. 

2  New  York  Med.  Rec,  1889,  vol.  i.,  p.  461. 


Plate  7. 


Gangrene  from  arterial  thrombosis 


GANGRENE  FROM  BLOOD-VASCULAR    OBSTRUCTLON.  2 1 9 

The  elastic  band  has  been  applied  so  as  to  cut  off  the  circulation  in 
a  limb  for  as  long  as  four  hours.  Such  application  is  apt  to  be  fol- 
lowed by  dilatation  of  the  arterioles  from  loss  of  tone  and  by  venous 
congestion,  in  consequence  of  which  sloughing  of  the  skin  has  taken 
place  (Wilkes 1).  When  the  elastic  tourniquet  is  applied  below  the 
elbow  or  knee,  the  wall  of  the  artery  may  be  bruised  and  thrombosis 
set  up.  Gangrene  of  a  finger  or  of  a  thumb  has  been  brought  about 
by  an  elastic  band  being  placed  round  the  base  to  stop  bleeding. 

Thrombosis  in  a  large  vein  is  caused  by  compression  and  also  by 
an  increased  coagulability  of  the  blood.  This  latter  is  due  to  septic 
causes,  and  follows  especially  puerperal  and  typhoid  fevers ;  it  is  prob- 
ably connected  with  an  excessive  destruction  of  leukocytes.  The 
thrombosis  of  a  main  vein  from  such  a  cause  is  frequently  accompanied 
or  followed  by  thrombosis  of  the  corresponding  artery. 

Obstruction  of  the  Abdominal  Aorta  and  its  Branches. — 
The  abdominal  aorta  may  be  obstructed  congenitally,  also  by  an  aneu- 
rysm which  has  been  obliterated  by  clot,  by  thrombosis  from  athero- 
matous disease  or  injur}',  and  by  embolism.  Obstruction  of  the  ab- 
dominal aorta  may  give  rise  to  no  obvious  symptoms,  unless  there  be 
in  addition  a  simultaneous  obstruction  of  the  iliacs.  When  the  throm- 
bosis extends  into  the  femorals,  severe  symptoms  arise,  owing  to  the 
interference  with  the  collateral  circulation  through  the  epigastrics  from 
the  internal  mammary  and  lumbar  arteries.  When  the  femoral  also  is 
blocked  by  a  clot,  more  especially  if  the  thrombosis  extends  into  the 
popliteal,  gangrene  follows. 

The  premonitory  signs  of  gangrene  peculiar  to  obstruction  of  the 
aorta  combined  with  those  of  its  branches  are  symmetrical  intermittent 
lameness  and  symmetrical  paralysis,  and  paraplegia. 

Intermittent  lameness  from  obstruction  of  the  abdominal  aorta  and  iliacs  has  received 
the  special  attention  of  French  writers.  Its  occurrence  in  the  horse  was  noted  by  Boullay,'2 
Humbert,3  and  others,  and,  later  in  man,  by  Charcot.4  The  horse  starts  out  of  the  stable 
apparently  sound,  but,  being  pushed  to  a  hard  trot,  comes  suddenly  to  a  standstill.  The 
animal  breaks  into  a  sweat  while  the  hind  limbs  are  rigidly  immobile,  or  falls  to  the  ground 
in  great  pain  with  the  hind  limbs  rigidly  extended.  The  symptoms  pass  off  after  a  short 
rest  to  reappear  on  forced  muscular  exertion. 

Numerous  dissections  have  shown  that  this  intermittent  lameness  is  caused  by  thrombosis 
of  the  hind  end  of  the  abdominal  aorta  and  of  the  iliacs,  due  either  to  a  rupture  of  the 
inner  coats  by  strain,  or  to  arteritis  in  connection  with  overwork.  The  rigidity  is  ischemic, 
a  condition  of  temporary  rigor  mortis  produced  in  the  muscles  by  cutting  off  the  circulation 
(Brown-Sequard  5). 

Painful  intermittent  lameness  and  paralysis  were  due  in  Charcot's  case  to  a  traumatic 
aneurysm  caused  by  a  bullet  that  had  obliterated  the  common  iliac  artery.  The  symptoms 
appeared  on  walking  and  passed  off  on  rest.  Death  occurred  from  bursting  of  the  aneurysm 
into  the  intestines.  In  Terrillon's6  case  of  a  hard  drinker  aged  twenty-seven,  the  pain  came 
on  in  the  leg  and  foot  immediately  on  movement,  so  that  he  could  go  only  a  few  steps,  and 
then  all  further  motion  became  impossible.  He  had  no  pain  whilst  at  rest.  These  symp- 
toms continued  for  two  years.  The  limb  became  colder  and  gradually  gangrene  supervened  and 
extended  to  the  middle  of  the  leg.  In  Jean's7  case  a  woman  aged  thirty-eight  had  for  some 
years  become  paraplegic  on  any  extra  exertion.      After  rest  she  was  able  to  get  about  again, 

1  Med.   Times  and  Gazette,  1880,  vol.  i.,  p.  540. 

2  Archiv gen.  de  Med.,  1831,  t.  xxviii.,  p.  425. 

3  Rec.  de  Med.  Vet.,  1884,  vol.  ii.,  p.  440,  and  many  other  cases  in  later  volumes  of  this 
periodical.  *  Gaz.  mid.  de  Paris,  1859,  p.  282. 

5  Lecons  sur  les  principales  formes  de  Paralysie  des  membres  inferieures,  1865,  p.  68. 

6  Revue  de  Chir.,  1886,  vol.  vi.,  p.  813. 

7  Bull,  de  la  Soc.  Anat.  de  Paris,  3me.,  ser.  x.,  1875,  p.  232. 


220  INTERNATIONAL    TEXTBOOK  OF  SURGERY. 

but  tlit'  legs  began  to  drag  afresh  upon  the  leasl  fatigue.  Gradually  the  paraplegia  became 
continuous,  and  she  died  of  enteritis.  The  aorta  and  common  iliacs  were  found  completely 
blocked,  the  anastomosing  vessels  dilated,  the  femorals  ami  popliteals  normal.  Sometimes 
the  onset  of  the  obstruction  is  obscure  ;  in  others  it  is  well  marked,  some  improvement  taking 
place  afterward  as  the  collateral  circulation  increases.  In  Gull's1  case  a  man  of  thirty-four 
felt  a  sudden  pain  in  the  loins,  with  desire  to  go  to  stool.  He  became  completely  paraplegic 
from  the  loin  downward,  including  the  sphincters.  After  a  few  days  there  was  a  return  of 
sensation,  and  later  on  he  was  able  to  take  a  few  steps,  but  was  soon  brought  to  a  standstill 
by  increasing  numbness.  He  gradually  recovered  walking  power,  but  the  muscles  were 
thin  and  languid,  the  feet  cold  and  damp.  No  pulsation  could  be  felt  in  the  aorta  or  femo- 
rals. The  superficial  epigastrics  were  much  dilated  and  the  blood-stream  in  them  down- 
ward.     The  lumbar  and  intercostals,  likewise,  were  much  dilated  right  up  to  the  axilla. 

A  man  of  forty-two,  described  by  Olliver,2  suffered  from  syphilitic  arteritis  and  thrombosis. 
Pain  and  coldness  suddenly  started  in  his  foot  while  at  dinner.  The  great  toe  became  very 
cold  and  swollen,  the  limbs  full.  After  he  had  walked  for  two  or  three  minutes,  he  had  to 
stop  suddenly,  but  while  resting  he  felt  no  pain.  These  symptoms  abated  in  warm  weather 
and  were  easily  borne.  The  symptoms  were  most  marked  in  the  right  limb,  no  pulsation 
could  be  felt,  and  the  limb  atrophied.  On  the  left  side  they  were  less  severe  and  some  pul- 
sation could  be  felt  in  the  arteries. 

The  obstruction  of  the  aorta  and  its  branches  may  occur  symmetri- 
cally with  great  suddenness  as  a  complication  of  some  exhausting  ill- 
ness. Latterly  a  number  of  cases  have  been  recorded  following  upon 
influenza  (Gould).  Gangrene  sets  in,  and  the  determining  cause  of  the 
gangrene  may  be  found  in  the  obstruction,  not  only  of  the  aorta  and 
iliacs,  but  also  of  femorals  and  popliteals.  When  the  obstruction  is 
less  extensive,  the  force  of  the  heart  may  be  sufficient  to  develop  the 
collateral  circulation.  When  there  is  thrombosis  in  the  veins  as  well 
as  in  the  arteries,  the  gangrene  is  moist ;  when  only  in  the  latter,  the 
gangrene  may  be  dry  in  the  leg  and  foot. 

Treatment. — When  the  premonitory  symptoms  above  described 
are  recognized,  or  when  the  limb  is  found  cold,  dead-white,  and  all 
sensation  and  pulsation  are  absent,  the  limb  must  be  wrapped  in  cot- 
ton wool  and  raised  in  order  to  favor  the  venous  circulation.  Rest 
is  required  lest  any  further  clot  may  be  detached  and  pass  into  periph- 
eral vessels.  This  treatment,  along  with  an  improvement  in  the  gen- 
eral circulation,  may  give  time  for  anastomosis.  Gangrene  having  set 
in,  it  is  necessary  to  decide  whether  the  case  is  hopeless,  or  whether 
an  attempt  should  be  made  to  save  life.  If  amputation  seems  advis- 
able, it  should  be  done  without  delay.  If,  as  is  usually  the  case,  the 
gangrene  is  symmetrical,  it  is  all  the  more  important  to  attack  the 
most  advanced  leg  early,  so  as  to  allow  an  interval  of  a  few  days  or  a 
week  to  elapse  before  the  second  leg  is  removed  (Gould3).  On  the 
other  hand,  the  gangrene  may  be  so  far  advanced  that  the  removal  of 
the  two  legs  has  to  be  done  simultaneously.  The  leg  should  be  ampu- 
tated through  the  middle  or  junction  of  the  middle  and  lower  thirds 
of  the  thigh.  As  mentioned  above,  gangrene  is  as  likely  to  set  in 
when  the  femoral  is  obstructed  as  when  the  aorta  and  iliacs  are.  The 
blood  to  supply  the  flaps  has  to  gain  the  profunda  vessels  by  anas- 
tomosis. If  the  amputation  were  to  be  made  lower,  the  blood  from 
the  branches  of  the  profunda  femoris  would  have  to  pass  through  a 
second  set  of  arterioles  into  the  branches  of  the  popliteal  and  tibials. 
To  amputate  lower  is  to  court  recurrence  of  gangrene  in  the  stump. 

1  Guy's  Hospital  Reports,  1857,  3d  series,  vol.  iii.,  pp.  311-314,  with  plate. 

2  Observations  pour  servir  a  l'histoire  de  la  claudication  intermittente  chez  1'homme. 

3  Brit.  Med.  Jour.,  1891,  vol.  i.,  p.  639. 


Plate  8. 


Gangrene  from  embolism. 


GANGRENE   FROM  BLOOD-VASCULAR    OBSTRUCTION.  221 

Obstruction  to  the  Femoral  Artery  and  Vein. — The  common 
femoral  formerly  proved  a  dangerous  artery  to  ligature  in  continuity, 
and  half  the  cases  of  obstruction  terminated  in  gangrene.  But  by 
avoiding  injury  to  the  vein  and  septic  complications  it  has  been  found 
that  the  common  femoral  artery  can  be  safely  ligated.  A  wound  in 
Scarpa's  triangle  is  likely  to  cause  gangrene  on  account  of  concurrent 
injury  to  the  vein  and  to  septic  complications  in  a  patient  whose  gen- 
eral circulation  has  been  weakened  by  primary  hemorrhage.  Although 
it  has  been  found  possible  to  ligature  successfully  both  the  common 
femoral  artery  and  vein,  yet  this  should  be  avoided  if  possible.  A 
wound  of  the  vein  may  be  blocked  by  clot  after  pressure  has  been 
kept  up  for  a  short  time,  or  a  lateral  ligature  or  suture  may  be  applied. 
Should  a  tumor  in  the  groin  involve  all  three  branches  of  the  common 
femoral  vein,  it  would  be  advisable  to  proceed  to  amputation  at  once 
rather  than  run  the  almost  inevitable  risk  of  gangrene  following  the 
simple  removal.  If,  however,  only  one  vein  is  involved,  the  two  others 
are  sufficient  to  return  the  blood,  and  the  internal  saphena  should 
always  be  carefully  preserved,  not  divided,  in  the  early  steps  of  an 
operation. 

Obstruction  to  the  Superficial  Femoral  and  the  Popliteal 
Arteries  and  Veins. — The  superficial  femoral  artery  and  vein  can 
be  tied  simultaneously  in  Hunter's  canal  without  danger  to  the  limb, 
and  the  same  thing  has  been  done  with  the  popliteal  artery  and  vein 
(Teale1).  The  success  of  such  operations  implies  patency  of  the  anas- 
tomosing vessels.  But  gangrene  is  still  of  frequent  occurrence  as  a 
complication  of  ruptured  popliteal  aneurysm,  and  a  number  of  cases 
have  recently  been  recorded.  As  a  popliteal  aneurysm  develops  an 
obstruction  to  the  blood-flow  in  the  main  artery,  the  anastomotic  cir- 
culation through  the  articular  arteries  increases.  When,  however,  the 
aneurysm  grows  still  larger,  and  especially  when  it  ruptures,  it  com- 
presses the  articular  arteries  and  hinders  the  anastomotic  circulation 
already  established.  If  at  this  stage  the  superficial  femoral  arteiy  is 
ligated,  the  onset  of  the  gangrene  is  precipitated. 

Symptoms. — The  threatening  signs  of  oncoming  gangrene  are  as 
follows  :  The  limb  on  exertion  aches,  the  calf  muscles  become  rigid 
and  lose  power,  symptoms  of  intermittent  lameness  appear,  which  pass 
off  with  rest.  The  limb  may  become  paralyzed,  cold,  and  useless ; 
later  on  the  muscles  atrophy.  An  interstitial  myositis  is  started,  caus- 
ing degeneration  of  muscle-fibers  and  contracture  of  inflammatory 
tissue  (Spencer2).  Following  upon  ligation  of  the  femoral  in  conti- 
nuity, the  leg  may  remain  for  days  dead  white,  or  marbled  by  veins, 
cold  and  insensitive ;  the  epidermis  begins  to  separate.  Then  a  change 
comes,  either  in  the  direction  of  dry  gangrene,  or  toward  recovery  of 
warmth  and  sensation  with  a  development  of  the  pink  circulation 
beneath  the  toe-nails.  In  the  former  case  the  circulation  may  return, 
but  too  late  ;  the  anterior  part  of  the  foot  and  the  toes  become  flushed 
with  blood,  but,  the  capillaries  having  already  degenerated,  the  blood 
is  extravasated  in  and  beneath  the  skin. 

Treatment. — Such  cases  of  gangrene  are  to  be  avoided  by  early 

1  Lancet,  1887,  vol.  i.,  p.  12.     Newbolt,  Ibid.,  1898,  vol.  i.,  p.  11 16. 

2  Westminster  Hospital  Reports,  1 89 1,  vol.  vii.,  p.  16. 


222  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

treatment  of  the  popliteal  aneurysm,  and  by  selecting  the  direct  oper- 
ation whenever  rupture  has  occurred.  Through  a  posterior  median 
incision  all  the  blood-clot  should  be  turned  out;  the  articular  arteries 
are  relieved  from  compression,  and  need  not  be  further  injured.  In 
tying  the  popliteal  artery  above  and  below  the  aneurysm,  it  may  be 
possible  to  spare  the  vein. 

When,  however,  gangrene  has  set  in,  and  has  spread  beyond  the 
toes,  amputation  should  be  done  through  the  knee-joint.  The  artic- 
ular arteries  will  receive  enough  blood  from  the  profunda  branches  to 
supply  the  flaps,  but  the  blood-pressure  in  them  would  not  be  suf- 
ficient to  produce  a  passage  into  the  branches  of  the  tibials. '  To  wait 
and  then  amputate  lower  down  is  to  render  probable  gangrene  of  the 
flaps,  necessitating  another  amputation,  which  even  a  previously  strong 
patient  may  not  sustain.  There  is  no  need  to  amputate  higher  than 
the  knee  unless  the  amputation  has  been  delayed  until  septic  changes 
have  taken  place  and  caused  thrombosis  of  the  articular  arteries.  To 
wait  for  a  line  of  demarcation  and  spontaneous  separation,  when  the 
gangrene  has  extended  beyond  the  toes,  is  to  expose  the  patient  to 
much  suffering,  exhaustion,  and  septic  complications,  to  say  nothing 
of  the  delay.  Even  should  he  escape  these,  he  will  be  left  with  a  limb 
practically  useless  below  the  knee,  always  exposed  to  ulceration  from 
cold  or  slight  injury. 

Obstruction  to  the  Axillary  and  Brachial  Arteries  and 
Veins. — The  axillary  or  brachial  artery  is  liable  to  be  obstructed  by 
an  embolus  detached  from  the  heart,  the  embolus  commonly  blocking 
the  artery  immediately  below  the  axilla.  Sudden  thrombosis  may 
occur  as  in  Dujardin-Beaumetz's  1  case.  An  anemic  boy  of  eighteen 
suffered  from  obstruction  of  the  brachial  below  the  axilla,  no  pulsation 
could  be  felt  beyond  this  point,  and  the  forearm  and  hand  became 
gangrenous.  Amputation  through  the  middle  of  the  humerus  is 
necessary  under  such  conditions,  the  flaps  having  to  depend  upon  the 
branches  of  the  subclavian  and  upper  axillary  arteries. 

The  veins  of  the  arm  are  superficial.  A  tight  bandage,  in  particular 
a  plaster  bandage,  applied  directly  over  a  fracture  and  not  removed, 
has  caused  venous  congestion  of  the  hand,  then  ischemic  rigidity, 
paralysis,  and  even  gangrene  (Volkmann,2  Leser3). 

m.  GANGRENE  FROM  OBSTRUCTION  OF  THE  SMALLER  ARTERIES. 

Arteriosclerotic,  Senile,  Diabetic,  and  Albuminuric  Gan- 
grene.— Atheromatous  and  calcareous  thickening  of  the  intima  in  the 
smaller  arteries  is  essentially  a  senile  change,  and  is  an  especial  cause 
of  gangrene  when  it  affects  the  tibial  arteries.  Not  only  does  the 
lumen  of  the  artery  become  exceedingly  small,  but  it  may  at  any  time 
be  obliterated  by  a  thrombus.  This  senile  change  appears  early  and 
advances  to  a  more  extreme  degree  in  those  who  have  been  affected 
by  syphilis,  who  have  taken  alcohol  to  excess,  who  have  suffered  from 
overwork,  hardships,  or  exposure.     As  concomitant  results,  there  may 

1  Bull,  et  Mint,  de  la  Soc.  Med.  des  Hop.  de  Paris,  1875,  t.  xi.,  pp.  213,  219. 

2  Centralblatt  ficr  Chirurgie,  1881,  p.  801. 

3  Volkmann' s  Klinische  Sammlung,  No.  249;   Chirurgie,  No.  77. 


GANGRENE   FROM   OBSTRUCTION   OF  SMALLER   ARTERIES.     223 

be  found  in  the  same  patient  cardiac  hypertrophy  and  high  pulse  tension 
tending  to  apoplexy,  chronic  nephritis  causing  albuminuria,  diabetes, 
obesity,  and  gout.  The  radial  and  temporal  arteries  will  be  hard  and 
tortuous.  One,  several,  or  all  of  these  conditions  may  coexist,  to  which 
gangrene  supervenes  as  a  late  complication.  The  determining  factor  is 
the  extent  of  the  narrowing  and  thrombosis  of  the  tibial  arteries.  The 
gangrene  nearly  always  appears  in  the  lower  limb.  It  occurs,  Pott 
said,  in  twenty  men  to  one  woman. 

Symptoms. — The  premonitory  symptoms  are  important,  for  by  rec- 
ognizing them  we  may  be  able  to  ward  off  the  gangrene.  Attention  is 
first  drawn  to  the  limb  by  cramping  pains,  numbness  and  cold,  alterna- 
ting with  heat  and  tingling,  formications,  a  sense  of  weight  or  of  fulness, 
a  diminution  of  sensation,  so  that  a  thick  sock  seems  to  be  interposed 
between  the  bare  foot  and  the  floor.  The  patient  may  complain  that  at 
night  sleep  is  disturbed  by  cramp  followed  by  cold  sweats.  Symptoms 
similar  to  Raynaud's  disease  may  arise,  the  toes  may  become  dead  and 
cold  in  the  morning  when  getting  up,  or  after  meals.  In  other  cases,  the 
complaint  is  that  intermittent  lameness,  obscure  pains,  rigidity,  and  pare- 
sis come  on  while  walking,  and  pass  off  on  rest.  On  examination  the 
foot  will  be  found  cold,  pale,  and  shrivelled.  Pulsation  cannot  be  felt  in 
the  dorsalis  pedis  and  posterior  tibial  arteries.  There  is  impaired  sen- 
sation, the  upper  limit  of  which  forms  more  or  less  of  a  circle  round 
the  limb  and  does  not  lie  in  any  particular  nerve-area.  The  diagnosis 
of  arteriosclerosis  is  confirmed  by  finding  tortuous,  hard  temporal  and 
radial  arteries  with  a  high  pulse  tension.  The  gangrene  generally 
shows  first  in  the  big  toe,  on  the  dorsum,  or  to  one  side  of  the 
nail.  The  skin  becomes  a  bluish  red  which  does  not  disappear  on 
pressure.  A  dusky  scurf  or  a  brown  horny  scale  is  seen,  or  a  black 
spot  of  skin,  beneath  which  is  a  dusky  ulcer.  A  blister  may  arise  con- 
taining reddish  serum,  and  when  the  covering  epidermis  is  raised,  dusky 
red  papillae  are  exposed.  Some  slight  mechanical  violence  may  be  the 
exciting  cause ;  the  black  spot  begins  where  the  boot  has  pressed  on 
the  toe,  or  at  the  site  of  a  corn  where  a  little  cut  has  been  made  in  re- 
moving it.  A  slight  squeeze,  from  the  toe  being  stepped  on,  or  a  nail 
projecting  up  from  the  sole  of  the  boot,  may  start  the  gangrene.  The 
scab  may  separate  and  the  gangrenous  ulcer  heal,  only  to  break  down 
again.  The  ulcer  may  extend  to  the  bone,  causing  a  perforating  ulcer, 
at  the  bottom  of  which  insidious  necrosis  goes  on.  Extension  to  the 
rest  of  the  toe  and  foot  is  marked  by  edema,  the  pitting  of  the  skin 
not  disappearing  quickly  when  the  pressure  of  the  finger  is  relaxed ; 
the  skin  of  the  dorsum  of  the  foot  becomes  dusky  red,  and  does  not 
alter  on  pressure,  but  grows  darker.  The  gangrene  is  usually  dry  ;  a 
line  of  demarcation  forms  round  the  toe,  or  at  some  point  across  the 
foot,  or  around  the  ankle.  In  a  stout  alcoholic  patient,  when  once 
started,  gangrene  may  rapidly  spread  and  become  moist. 

Treatment. — The  gangrene  is  prevented  by  exercise,  massage,  and 
baths  which  favor  the  circulation  in  the  limb  and  hinder  the  advance 
of  arteriosclerosis.  The  feet  must  be  kept  clean  by  bathing  in  warm 
water  and  drying,  lest  eczema  be  caused  by  dirt  and  sweat.  Nails  and 
corns  have  to  be  pared  carefully,  so  that  no  lesion  of  the  skin  occurs. 
Woollen  socks   reaching  up  to  the  knee  are  to  be  worn  both  by  day 


224  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

and  night.  The  feet  must  be  kept  warm  by  exercise,  never  heated  at 
the  fire,  for,  sensation  being  diminished,  dangerous  congestion,  scorch- 
ing, or  burning  may  take  place  unperceived  by  the  patient.  Large 
well-fitting  shoes  are  to  be  worn  to  avoid  pressure,  corns,  and  blisters. 
The  patient's  general  health  should  be  improved  by  the  active  treat- 
ment of  syphilis,  gout,  diabetes,  or  albuminuria. 

The  circulation  generally,  including  that  of  the  extremities,  will 
probably  be  benefited  by  coffee.  Opium  acts  likewise  by  dilating  the 
capillaries  ;  it  also  relieves  pain  and  tends  to  diminish  the  amount  of 
sugar  when  diabetes  is  present.  Small  doses  of  opium  are  quite  well 
taken  although  there  be  albuminuria.  When  the  patient  has  taken 
much  alcohol,  the  amount  should  be  reduced  to  a  minimum,  and 
whenever  possible  stopped  altogether;  its  place  is  much  better  filled 
by  quinin.  When  a  black  patch  appears  it  should  be  dusted  with 
iodoform  and  kept  quite  dry.  The  leg  and  foot  are  to  be  wrapped 
up  in  cotton  wool,  and  the  patient  must  sit  in  a  chair  during  the  day 
with  the  foot  raised.  The  foot  should  not  be  cut  nor  poulticed,  nor 
soaked  in  hot  water,  nor  warmed  by  the  fire,  nor  by  contact  with  a 
hot-water  bottle.  These  methods  all  provoke  the  spread  of  the  gan- 
grene. The  local  conditions  may  favor  healing ;  the  black  scab  may 
separate  and  the  ulcer  heal ;  a  line  of  demarcation  may  form,  and 
the  toe  slowly  separate.  This  occurs  when  the  patient's  health 
improves,  when  he  is  free  from  pain  and  fever,  eats  and  sleeps  well, 
and  the  sugar  and  albumin  in  the  urine  are  reduced.  On  the  other 
hand,  the  gangrene  may  gradually  spread,  the  patient's  health  get 
worse,  and  some  fatal  complication  occur,  such  as  cerebral  apoplexy, 
uremic  or  diabetic  coma,  or  bronchopneumonia. 

When  the  gangrene  has  spread  to  the  foot  and  the  patient  is  suffer- 
ing from  septic  absorption,  the  removal  of  the  gangrene  becomes 
urgent.  Even  if  there  is  not  much  absorption,  owing  to  the  dryness 
of  the  gangrene,  yet  the  slowness  of  the  separation  and  the  pointed 
stump  left  will  slowly  undermine  an  old  patient  who  is  prevented  during 
all  this  time  from  taking  open-air  exercise.  Until  recently  removal 
of  the  gangrene  was  usually  followed  by  further  sloughing  of  the  flap 
and  necrosis  of  bone.  This  recurrence  of  the  gangrene  is  independent 
of  the  aseptic  character  of  the  amputation,  and  is  simply  due  to  the 
narrowed  and  thrombosed  tibial  arteries  and  their  branches.  Amputa- 
tion through  the  foot,  ankle,  or  leg  has  been  followed  in  a  great  num- 
ber of  cases  by  gangrene  of  the  stump.  A  second,  and  even  a  third, 
amputation  has  had  to  be  done,  but  there  are  very  few  of  the  patients 
who  can  survive  gangrene  of  the  flaps  and  reamputation.  It  was  first 
proposed  by  Hutchinson1  that  these  cases  should  be  amputated  through 
the  lower  third  of  the  thigh,  where  the  main  artery  and  its  branches 
are  tolerably  free  from  calcareous  degeneration.  Experience  has  amply 
proved  that  this  is  the  one  method  of  ensuring  success  ;  the  rule  must 
be  "  high  amputation,"  or  none  at  all.  It  has  been  objected  to  the 
high  amputation  that  it  causes  more  shock  than  the  low  amputation. 
As  a  matter  of  fact,  the  difference  is  not  perceptible  after  an  amputation 
by  present  methods,  and  the  primary  union  which  follows  renders  the 
high  amputation  the  safer.     It  has  been  further  objected  that  there  is 

1  Med.-Chir.   Trans.,  1884,  vol.  lxvii.,  p.  97. 


GANGRENE   FROM   OBSTRUCTION   OF  SMALLER   ARTERLES.     225 

an  unnecessary  sacrifice  of  limb,  to  which  the  reply  may  be  made  that 
the  patients  are  usually  past  active  work  and  can  get  about  quite  well 
enough  with  the  shorter  stump.  The  primary  union  which  takes  place 
in  the  thigh  allows  of  an  artificial  limb  being  readily  adjusted  and 
easily  worn. 

It  is  hardly  necessary  to  distinguish  sharply  the  various  cases  ac- 
cording to  their  complications — senile  gangrene,  diabetic  gangrene,  etc. 
Old  age,  heart  disease,  bronchitis,  obesity,  gout,  diabetes,  and  albumi- 
nuria, all  increase  the  gravity  of  the  case,  but  do  not  constitute  an 
absolute  bar  to  the  operation.  When  there  are  both  sugar  and  albumin 
in  the  urine  to  a  considerable  amount,  the  chances  of  prolonging  life 
are,  of  course,  unfavorable ;  but  when  there  is  only  one  of  the  two 
present,  or  one  with  mere  traces  of  the  other,  amputation  may  well  be 
successful  (Kuster-Heidenhain,1  Spencer,2  Godlee3).  The  high  ampu- 
tation must  always  be  done  so  as  to  obtain  primary  union,  there  should 
be  no  loss  of  blood  beyond  that  in  the  limb  at  the  time,  and  antisep- 
tics like  carbolic  acid  or  perchlorid  of  mercury  should  not  be  used 
except  for  the  skin,  lest  absorption  take  place.  Experience  has  shown 
that  along  with  the  healing  of  the  stump  the  albumin  or  sugar,  or  both, 
have  fallen  to  a  small  amount.  In  many  cases  of  chronic  albuminuria 
or  diabetes  life  has  been  much  prolonged  by  this  amputation.  The 
bad  results  formerly  obtained  when  the  urine  contained  albumin  or 
sugar  were  due  either  to  the  operation  being  septic  or  to  the  insufficient 
blood-supply  in  the  stump.  Before  performing  the  high  amputation 
the  surgeon  can  convince  himself  of  the  correctness  of  the  diagnosis 
and  treatment  by  cutting  across  the  tibial  arteries,  when  they  will  be 
found  scarcely  to  bleed  at  all.  It  need  hardly  be  added  that  amputa- 
tion through  the  knee-joint  is  less  suitable ;  owing  to  the  long  thin 
flaps  supplied  by  the  popliteal  articular  arteries,  which  may  be  partially 
sclerosed,  the  amputation-flaps  should  depend  upon  the  branches  of 
the  deep  femoral  for  their  blood-supply. 

Gangrene  due  to  Arteritis  Obliterans. — Arteritis  or  endarteri- 
tis obliterans  is  the  name  given  to  a  fibrous  thickening  of  the  internal, 
and  to  a  less  extent  of  the  middle,  coat  of  the  smaller  arteries.  If  it 
progresses  far  enough,  the  lumen  of  the  vessel  may  be  practically 
obliterated,  and  the  larger  arteries  on  the  proximal  side  undergo  throm- 
bosis ;  and  hence,  if  the  disease  attacks  the  vessels  of  the  limbs,  gan- 
grene may  follow. 

Obliterative  arteritis  is  best  known  from  its  occurrence  in  the  syl- 
vian, vertebral,  coronary,  and  pulmonary  arteries,  the  increase  of  fibrous 
tissue  being  generally  concentric,  less  often  eccentric,  causing  the 
appearance  of  a  nodule  on  one  side  of  the  artery.  The  affection  of 
these  arteries  is  without  doubt  due  in  many  cases  to  syphilis,  but  there 
does  not  seem  to  be  any  special  microscopic  lesion  distinctive  of  syph- 
ilis. If  one  can  conclude  from  the  failure  of  antisyphilitic  remedies  in 
such  cases,  one  may  look  at  the  lesion  as  a  post-syphilitic  one.  But 
physicians  are  generally  disposed  to  admit  that  obliterative  arteritis 
may  occur  in  patients  who  have  not  had  syphilis  or  indulged  in  alcohoL 

1  Kiister's  cases.      Vide  Heidenhain,  Detttsch  Med.   IVochenschrift,  1891,  S.  1087. 

2  Med.-Chir.  Trans.,  1892,  p.  395. 
s  Ibid.,  1893,  p.  37. 

15 


226  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Friedlander1  compared  the  thickening  of  the  intima  to  that  which 
causes  the  obliteration  of  the  ductus  Botalli,  the  hypogastric  arteries, 
and  those  of  the  uterus  during  involution  after  pregnancy. 

In  the  group  of  cases  to  which  attention  is  here  drawn,  the  obliter- 
ative  arteritis  has  affected  the  vessels  of  the  limbs  and  threatened,  or 
actually  produced,  gangrene.  The  cause  is  quite  obscure,  a  history  of 
syphilis  or  of  alcoholism  being  distinctly  absent.  Clinically  the  cases 
are  to  be  distinguished  by  the  absence  of  heart  disease  or  of  any  pre- 
vious illness  likely  to  originate  embolism  or  thrombosis.  The  patients 
are  not  affected  by  atheromatous  disease  or  calcareous  degeneration 
causing  arteriosclerosis,  for  they  are  young  adults,  presenting  no  senile 
changes,  no  tortuous  temporal  nor  radial  arteries ;  the  affected  vessels 
simply  feel  like  a  cord.  The  disease  is  not  attended  by  albuminuria, 
cardiac  hypertrophy,  nor  excessive  pulse  tension  in  the  patent  vessels. 
In  Raynaud's  gangrene,  to  be  described  later,  there  is  spasm  of  the 
arterioles,  not  a  change  in  the  vessel-walls. 

The  case  of  arteritis  obliterans  described  by  Pearce  Gould2  has 
been  under  observation  for  a  long  time.  The  patient  presented  pecu- 
liarly characteristic  features  ;  the  disease  occurred  in  a  young  adult,  in 
the  absence  of  the  known  causes  of  arterial  disease  ;  it  progressed  for  a 
time,  was  then  spontaneously  arrested,  and  was  followed  by  a  restora- 
tion to  health,  which  has  been  maintained  for  a  period  of  years. 

A  man,  nineteen  years  old  when  first  seen,  worked  in  a  brick-field,  but  had  not  been  exposed 
to  wet  and  cold.  When  aged  twelve  he  had  suffered  from  scarlet  fever  complicated  by  dropsy 
and  convulsions,  as  many  as  45  fits  occurring  in  a  day.  From  this  he  apparently  quite  recov- 
ered. When  thirteen  he  had  a  whitlow  on  the  right  little  finger  ;  at  seventeen  he  struck  his 
right  fifth  metacarpal  bone  and  a  thickening  resulted.  He  was  a  teetotaler,  and  had  never  had 
venereal  disease.  He  first  noted  that  the  fingers  of  the  right  hand  became  dark,  then  that 
the  right  hand  and  forearm  became  cold,  weak,  and  painful  whilst  at  work,  so  that  he  was 
forced  to  stop,  but  after  an  hour's  rest  the  hand  became  warm  again.  When  first  seen,  the 
brachial  artery  pulsated  down  to  a  point  just  above  the  elbow,  below  which  it  formed  a 
pulseless  cord.  Whilst  under  observation  the  pulse  in  the  brachial  gradually  disappeared  as 
far  up  as  the  axillary  artery,  but  the  superior  profunda  artery  could  be  felt  above  the  outer 
condyle  of  the  humerus.  Dry  gangrene  attacked  the  ends  of  the  thumb,  middle,  and  ring- 
fingers,  and  the  dead  parts  were  later  on  removed.  No  other  lesion  was  found.  He  was  seen 
again  when  aged  twenty-two  ;  the  third  part  of  the  right  subclavian,  the  axillary,  and  the 
arteries  below  formed  cords  without  pulsation.  No  further  gangrene  had  appeared.  The 
man  was  heard  of  again  when  thirty  years  old  ;  he  was  well  and  doing  all  his  work. 

Hadden3  described  a  similar  case  in  a  young  woman. 

The  following  is  the  brief  account  of  a  more  advanced  case  under  the  writer's  care  :  *  An 
omnibus  driver,  aged  twenty-seven,  had  had  no  previous  illness  except  that,  eleven  years  before, 
he  had  had  gonorrhea  and  sores  which  lasted  nine  weeks.  No  signs  of  syphilis  followed. 
He  was  married  and  had  two  children.  His  urethra  was  found  on  examination  to  be  nor- 
mal. He  had  not  taken  alcohol  to  excess.  His  mother  and  two  brothers  had  died  of 
phthisis  and  a  sister  was  suffering  from  her  chest.  He  had  noted  that  for  three  months — 
July,  August,  and  September — his  left  foot  had  at  times  become  cold,  so  that  he  had  fre- 
quently to  rub  it  in  order  to  keep  it  warm.  He  also  had  a  sore  on  his  little  toe,  which 
healed  and  then  reappeared  three  weeks  before  he  was  first  seen.  Then  followed  a  change 
in  the  color  of  the  left  foot  to  a  bluish  red.  It  became  very  painful,  especially  at  night, 
across  the  base  of  the  toes,  and  a  black  spot  appeared  on  the  great  toe.  When  first  seen, 
dry  gangrene  had  affected  the  great  and  little  toes  and  threatened  to  set  in  on  the  instep  and 
skin  of  the  leg.  No  pulsation  could  be  felt  in  the  left  thigh  and  leg,  a  hard  cord  being  felt 
in  the  position  of  the  femoral  artery  ;  the  veins  were  unobstructed.  The  right  foot  was  cold 
and  damp,  but  not  painful.  On  the  plantar  surface  of  the  ungual  phalanx  of  the  great  toe 
was  a  superficial  dusky  patch.  No  pulsation  could  be  felt,  and  the  right  femoral  artery 
formed  a  cord.      No  pulsation  nor  sound  could  be  clearly  heard  in  the  abdominal  aorta  noi 

1  Centralb.  f.  d.  med.  Wissenschaften,  1876,  S.  64. 

2  Clinical  Society' ' s  Trans.,  1884,  p.  95  ;   1887,  p.  252  ;  also  note  given  to  writer. 

3  Ibid.,  1884,  p.  105.  *  Ibid.,  1898,  p.  89,  with  plates. 


GANGRENE  FOLLOWING    ON  SPASMS    OF   THE  ARTERIOLES.    22J 

in  the  iliacs.  The  right  hand  was  colder  than  the  left,  the  right  axillary  and  brachial 
smaller,  the  radial  artery  very  small,  but  soft  and  not  tortuous  ;  the  ulnar  artery  could 
scarcely  be  felt.  The  arteries  of  the  left  arm  were  normal,  the  pulse  being  of  low  tension. 
The  temporal  arteries  were  likewise  soft,  not  tortuous,  and  the  pulse  in  them  was  of  low 
tension.  The  heart,  lungs,  and  urine  were  normal.  Under  observation  the  pain  in  the  left 
leg  increased.  At  times  there  were  paroxysms  of  cramps,  when  the  calf  muscles  became  hard 
and  tender.  The  opium  he  was  given  had  gradually  to  be  increased  to  I  grain  (0.065  gm- ) 
of  ext.  opii  every  four  hours,  besides  which  as  much  as  three  injections  of  \  a  grain  (0.0324 
gm. )  of  morphin  were  required  during  the  day.  In  spite  of  the  narcotic  he  got  but  little 
ease  or  sleep,  he  was  generally  half-sitting,  looking  at  his  leg  with  an  anxious  expression, 
and  sweating.  He  became  thin  and  his  pulse  weaker.  During  the  week  before  the  ampu- 
tation dry  gangrene  began  in  the  skin  of  the  instep  and  of  the  front  of  the  leg  ;  the  tem- 
perature arose,  the  highest  point  being  101.20  F.  Amputation  was  done  through  the  middle 
of  the  left  thigh.  At  once  all  pain  was  lost,  he  recovered  his  appetite,  slept  well,  the  gen- 
eral circulation  improved,  but  there  was  no  increase  of  pulsation  in  the  obstructed  arteries. 
The  right  hand  and  foot  became  warmer,  and  the  right  foot  freely  desquamated.  Three 
years  later,  the  patient  was  well  and  was  following  his  former  employment.  At  the  amputation 
the  femoral  artery  was  found  blocked  by  a  firm  clot,  and  the  proximal  cut  end  did  not  pul- 
sate on  removing  the  elastic  band.  Besides  the  femoral  vein,  which  was  patent,  only  one 
small  artery  near  the  sciatic  nerve  was  tied  ;  there  were  no  other  bleeding  points  and  very 
little  oozing.  In  the  amputated  limb  the  popliteal  and  its  bifurcations  were  filled  by  a  firm, 
laminated  clot.  The  endothelium  and  the  intima  within  the  elastic  lamina  had  blended  with 
the  clot,  otherwise  there  was  no  obvious  change  in  the  vessel-wall.  The  lower  part  of  the 
tibials  was  thickened  but  empty,  the  lumen  being  smaller,  and  this  was  most  marked  in  the 
lower  end  of  the  posterior  tibial  and  in  the  plantars.  The  narrowing  was  caused  by  a  fibrous 
thickening  of  the  intima.  Where  less  marked  the  fibrosis  was  internal  to  the  elastic  lamina, 
which  was  unaltered  ;  where  the  disease  was  more  advanced  the  elastic  lamina  had  been 
replaced  by  fibrous  tissue,  and  there  was  some  invasion  of  the  middle  coat.  This  thickening 
of  the  intima  was  eccentric,  not  concentric  ;  in  one  quadrant  the  thickened  intima  projected 
into  the  lumen,  the  rest  of  the  circumference  being  altered  little  or  not  at  all.  The  intima 
of  the  corresponding  veins  was  also  slightly  affected.  The  arterioles  in  the  substance  of  the 
calf  muscles  were  unchanged.  Other  cases  in  which  gangrene  has  followed  arteritis  oblite- 
rans have  been  seen  in  older  patients,  but  it  may  be  questioned  whether  they  are  not  essen- 
tially different  from  those  just  described,  and  whether  such  cases  have  not  features  more 
nearly  allied  to  arteriosclerosis,  thrombosis,  etc.,  included  under  previous  sections  of  this 
article.  In  Winiwater's l  case  gangrene  attacked  the  foot  of  a  man  aged  fifty-seven.  In  the 
posterior  tibial  artery  and  vein  of  the  amputated  limb  was  found  an  endothelial  and  suben- 
dothelial  proliferation,  with  the  development  of  blood-vessels  in  the  media  and  intima.  The 
media  and  adventitia  were  also  affected,  but  to  a  less  extent  than  the  intima.  The  patient 
had  not  had  syphilis.  In  one  of  Widenmann's2  cases  a  man  of  sixty-five  was  attacked  with 
moist  gangrene  of  both  feet  simultaneously,  attended  by  high  fever.  He  had  also  marked 
emphysema  and  bronchitis,  tuberculosis  of  the  lungs,  and  a  dilated  heart,  but  no  sugar  nor 
albumin  in  the  urine.  He  had  not  had  syphilis.  The  vessels  were  not  tortuous.  Post 
mortem  there  were  found  in  the  tibials  a  marked  concentric  thickening  and  vascularity  of 
the  intima,  the  media  was  thickened,  and  in  it  some  lime  salts  were  deposited  ;  the  adventitia 
was  also  infiltrated.  The  lumen  was  occupied  by  organized  thrombi,  and  there  were  thrombi 
in  the  veins.  In  another  case  amputation  of  the  arm  was  done  for  moist  gangrene,  which 
had  begun  suddenly  fourteen  days  before,  after  an  attack  of  influenza.  The  man,  aged  forty- 
nine,  had  no  sugar  nor  albumin  in  the  urine,  nor  had  he  had  syphilis.  The  stump  bled  freely 
and  30  ligatures  were  used.  The  arteries  of  the  amputated  limb  were  thrombosed,  their 
coats  not  much  altered  ;  there  was  marked  thickening  of  the  intima  in  the  smaller  veins. 

IV.  GANGRENE  FOLLOWING  ON  SPASMS  OF  THE  ARTERIOLES. 
The  ends  of  the  fingers  and  toes,  the  tips  of  the  ears  and  of  the  nose 
suffer  from  the  intermittent  occurrence  of  pallor,  cold,  and  numbness 
due  to  arterial  constriction,  followed  by  redness,  heat,  and  tingling 
owing  to  arterial  relaxation.  Thrombosis  supervenes  on  prolonged 
constriction  and  blocks  the  small  veins  and  capillaries,  and  this  is  shown 
by  dusky  redness  which  does  not  disappear  on  pressure.  Recovery 
may  take  place  after  superficial  desquamation  or  ulceration.  The 
thrombosed  tissue  may  slowly  die,  causing  gangrene  of  the  dry  kind. 

1  Archiv  f.  klin.  Chirnrgie,  1878,  Bd.  xxiii.,  S.  202. 

2  Beitrdge  z.  klin.  Chirurgie,  1892,  Bd.  ix.,  S.  218. 


228  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Gangrene  from  Cold. — Chilblains. — A  slight  degree  of  throm- 
bosis produces  ulcerated  chilblains.  They  commonly  appear  in  anemic, 
badly  fed  children,  whose  hands  and  feet  are  not  kept  warm  and  dry 
and  whose  shoes  pinch  the  feet.  Patches  on  the  fingers  and  toes  are 
white  and  ache ;  on  being  warmed,  the  skin  turns  red  and  itches. 
When  thrombosis  occurs  the  spot  becomes  dusky  red  and  forms  an 
ulcer  from  which  a  slough  separates.  Chilblains  are  in  many  instances 
precursors  of  Raynaud's  gangrene. 

Chilblains  are  avoided  by  good  food,  by  daily  exercise,  by  woollen 
socks  and  gloves  worn  night  and  day  in  winter,  with  roomy,  good-fit- 
ting shoes.  The  hands  and  feet  are  not  to  be  put  suddenly  into  hot 
water  nor  warmed  before  the  fire.  Lukewarm  water  is  to  be  used  for 
washing,  after  which  the  hands  and  feet  are  to  be  rubbed  dry.  A 
chilblain  which  has  formed  and  threatens  to  ulcerate  should  be  painted 
with  iodin  tincture.  When  ulceration  has  taken  place,  a  mild  antiseptic 
ointment  is  applied. 

Frost=bite. — When  the  circulation  is  restored  after  pallor  caused  by 
cold,  there  are  bright  redness,  heat,  and  tingling.  When,  on  account 
of  the  prolonged  cold,  thrombosis  is  set  up,  there  are  dusky  redness, 
loss  of  warmth,  and  numbness.  Frost-bite  is  systematically  avoided  in 
cold  climates  by  keeping  the  extremities  warmly  covered.  The  cap 
covers  the  ears,  large  gloves  without  fingers  the  hands,  extra  large 
boots  are  worn,  so  that  the  feet  can  be  encased  in  thick  wool  stockings 
or  bands  of  hay.  The  tip  of  the  nose  is  exposed,  but  this  is  not  in 
danger  unless  there  is  in  addition  to  the  cold  a  damp  and  high  wind. 
But  when  predisposing  influences  come  into  play,  frost-bite  may  occur 
although  the  temperature  is  above  freezing  point.  Frost-bite  is  favored 
by  alcohol  on  account  of  the  greater  loss  of  heat  from  the  surface,  also 
by  fatigue  and  want  of  food.  A  man  who  has  plenty  of  food,  who 
avoids  fatigue  and  alcohol,  may  sleep  out  on  the  snow  without  harm, 
whilst  a  drunkard  asleep  on  damp,  unfrozen  ground  may  suffer.  Loss 
of  blood  favors  frost-bite  ;  hence  the  wounded  lying  out  at  night  after 
a  battle  are  liable  to  be  attacked. 

Treatment. — A  patient  affected  by  cold  and  threatened  with  frost- 
bite should  be  taken  into  a  room  of  the  ordinary  temperature,  but 
should  be  kept  away  from  the  fire.  The  threatened  extremities  are 
rubbed  with  snow  or  cold  water,  not  plunged  into  warm  water,  until  the 
circulation  improves ;  they  are  then  well  dried  and  wrapped  up.  The 
patient  is  given  hot  soup  and  coffee,  but  not  alcohol,  except  in  very 
small  amounts.  If  unconscious,  hot  nutrient  enemata,  with  or  without 
brandy,  are  administered,  and  plenty  of  covering  put  on  the  bed,  until 
warmth  and  consciousness  return.  A  part  becoming  gangrenous  is 
dusted  with  iodoform  under  a  thin  layer  of  wool.  The  gangrene  will 
be  dry,  and  generally  the  slough  may  be  allowed  to  separate  spon- 
taneously ;  at  least,  no  operation  is  permissible  until  the  patient  has 
recovered  from  the  general  effects  of  the  cold.  The  operation  is  usually 
limited  to  the  removal  of  the  bone  from  the  pointed  stump,  so  that  the 
skin-flaps  can  heal.  Moist  gangrene  and  septic  infection  are  unlikely  to 
happen,  unless  the  already  gangrenous  limb  is  kept  hot  and  moist. 

The  artificial  cold  produced  by  the  ether  spray  has  given  rise  to 
gangrene.     A  nodule  in  the  skin  was  removed  under  ether  spray  from 


Plate  9. 


\ 


Harrington's  case  of  carbolic  gan 


gangrene. 


GANGRENE    FOLLOWING    ON  SPASMS   OF  THE  ARTERIOLES.    229 

the  leg  of  a  woman  aged  seventy;  gangrene  spread  from  the  wound 
and  caused  death.  It  is  therefore  a  good  rule  not  to  freeze  the  skin 
of  old  people. 

Carbolic-acid  fomentations  have  caused  gangrene  of  the  fingers, 
therefore  boric  acid,  not  carbolic  acid,  should  be  used  for  fomentations 
(Peraire1).  This  misuse  of  carbolic  acid  continues,  and  further  cases  of 
gangrene  of  the  fingers  have  been  recently  reported. 

Gangrene  dne  to  Ergot. — Ergotism  is  the  result  of  eating  bread 
made  from  rye  affected  by  the  fungus,  especially  when  1  grain  in  8  or 
10  has  been  so  diseased.  It  is  met  with,  therefore,  only  in  those  who 
have  lived  upon  such  bad  bread,  and  the  severity  of  the  disease  depends 
upon  the  amount  taken.  The  rye  is  attacked  by  the  fungus  in  cold,  wet 
summers,  and  gangrene  from  ergot  could  not  be  seen  nowadays  except 
among  peasant  farmers  in  districts  unfavorable  for  agriculture,  where 
the  farmers  are  forced  to  eat  the  grain  they  cannot  sell.  The  disease 
has  been  met  with  during  the  last  two  centuries  in  France  and  Ger- 
many, not  in  the  British  Isles,  where  rye  is  hardly  ever,  or  never,  used 
for  bread.  Ergotism  was  reported  from  France  during  the  year  1897 
(Mongour2).  Ergot  is  produced  in  America,  but  ergotism  does  not 
seem  to  have  appeared.  Ergot  causes  gangrene  chiefly  in  middle-aged 
men,  much  more  rarely  in  women,  its  incidence  in  this  respect  resem- 
bling that  of  gangrene  due  to  arteriosclerosis.  Children  suffer,  both 
male  and  female,  but  less  often  than  men,  the  convulsive  form  of  ergot- 
ism being  more  marked.  But  there  must  be  some  special  predisposi- 
tion which  accounts  for  the  differences  in  susceptibility  among  members 
of  the  same  family  similarly  exposed  to  the  influence  of  the  poison. 

Although  ergot  has  often  been  administered  in  large  doses  for  long 
periods,  the  drug  has  never  been  known  to  cause  gangrene.  It  may 
therefore  be  supposed  that  the  gangrene  is  the  combined  result  of  ergot- 
ized  bread  and  insufficient  food.  The  gangrene  is  the  consequence  of 
long-continued  vascular  spasm  leading  to  thrombosis.  The  earlier 
symptoms  of  ergotism  are  due  to  constriction  of  the  blood-vessels  of 
the  central  nervous  system  and  of  the  intestine  :  they  are  giddiness,  dis- 
turbances of  vision  from  a  peculiar  sensibility  of  the  retina,  buzzing  in 
the  ears,  formication,  itching,  and  hyperesthesia  of  the  skin  ;  hence  the 
German  name  "  Kriebelkrankheit."  The  next  series  of  phenomena  are 
due  to  spasm  of  the  muscular  arterioles  causing  painful  creeping  and 
burning  cramps ;  from  these  burning  sensations  originate  the  French 
name  "  Mai  des  Ardents,"  and  the  old  English  one  "  St.  Anthony's  fire." 

The  gangrene  is  generally  dry  and  symmetrical,  and  affects  mostly 
the  feet,  although  the  fingers,  ears,  and  nose  have  been  attacked.  The 
gangrene  does  not  prevent  the  patient  from  getting  about ;  men  have 
been  seen  walking  on  the  dead  limb  as  on  an  efficient  stump.  The 
period  of  separation  is  a  prolonged  one,  two  years  or  more,  and  it 
usually  takes  place  at  one  of  the  joints  of  the  foot  or  at  the  ankle. 
The  line  of  demarcation  may  form  higher  up,  and  extreme  cases  have 
been  recorded  in  which  both  legs  sloughed  off  at  the  hip-joint  (Salerne3). 
The  main  arteries  are  thrombosed  and  occluded  early,  so  that  there  is 
no  danger  of  hemorrhage. 

Treatment. — The  earlier  symptoms  of  the  ergotism  being  present, 

1  Centralbl.  f.  Chirurgie,  1896,  S.  783.        2  Arch.  din.  de  Bordeaux,  1897,  t.  vi.,  p.  325. 
3  Vide  Duplay  et  Reclus,  Chirurgie. 


23O  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

gangrene  may  be  prevented  by  good  food,  warmth,  friction,  with  coffee 
and  opium  for  the  cramps.  The  gangrene  is  treated  expectantly,  any 
surgical  interference  being  put  off  until  the  patient's  general  health  is 
restored,  and  is  always  of  a  very  limited  character. 

I/ead  acts  in  a  similar  way  to  ergot  and  is  said  to  produce  gan- 
grene, or  rather  to  increase  the  ill  effect  of  other  causes,  such  as  arterio- 
sclerosis (Sainton  '). 

Raynaud's  Gangrene. — Raynaud's  gangrene  is  that  form  of  gan- 
grene which  results  from  a  prolonged  continuance  of  Raynaud's  symp- 
toms, the  characteristic  feature  of  which  is  a  generally  symmetrical  and 
paroxysmal  spasm  of  the  arterioles,  of  nervous  origin. 

Raynaud's  gangrene  should  not  be  extended  to  be  synonymous 
with  symmetrical  gangrene,  for  the  symmetry  may  be  due  to  throm- 
bosis. Indeed,  Raynaud's  symptoms  are  frequently  unilateral,  even 
limited  to  the  distribution  of  a  single  nerve.  Neither  is  Raynaud's 
gangrene  the  only  kind  that  is  preceded  by  paroxysmal  symptoms,  for 
both  obstruction  to  main  blood-vessels  and  arteriosclerosis  of  the  tibials 
are  attended  by  intermittent  paroxysms  which  gradually  lead  on  to 
gangrene.  There  is  no  doubt  that  Raynaud2  included  in  his  original 
essays  cases  of  gangrene  whose  pathology  widely  differed.  The  term 
"  Raynaud's  gangrene  "  should  be  applied  to  those  cases  in  which  there 
is  no  obstruction  of  the  main  arteries,  nor  arteriosclerosis,  the  onset  of 
which  is  preceded  by  characteristic  symptoms. 

At  least  two  well-marked  types  are  met  with.  One  occurs  in  anemic 
women  and  others  in  feeble  health,  including  lunatics,  or  in  those 
exhausted  by  disease,  such  as  ague,  all  with  a  feeble  pulse  of  low  ten- 
sion ;  the  treatment  of  this  type  is  practically  that  of  the  anemia. 
The  other  and  less  common  type  occurs  in  young  people  about 
puberty,  both  male  and  female,  and  is  characterized  by  a  pulse  of  high 
tension,  and  by  arteries  hypertrophied,  hard,  and  tortuous,  so  that  they 
can  be  rolled  beneath  the  fingers.  Such  patients  are  liable  to  the  com- 
plications ensuing  from  this  high  pulse  tension — viz.,  hemoglobinuria, 
purpura,  apoplexy  and  other  hemorrhages,  and  uremia  (Aitken,3  Osier4). 
The  spasm  of  the  arterioles  is  supposed  to  originate  in  some  blood- 
disease  causing  excessive  destruction  of  the  blood-corpuscles ;  hence 
the  excitation  of  vasoconstrictors,  accompanied  by  a  special  sensitive- 
ness to  changes  in  temperature,  and  neuroses  of  various  kinds.  Ray- 
naud used  two  words  in  a  special  way,  "local  asphyxia"  and  "local 
syncope."  He  applied  the  term  "  asphyxia,"  in  its  literal  sense  of 
"  want  of  pulse,"  to  the  dead-white  finger,  but  owing  to  a  confusion 
with  the  commoner  use  of  the  word  in  connection  with  carbonic-acid 
poisoning,  it  has  been  used  by  some  writers  for  the  subsequent  stage 
of  venous  congestion.  Raynaud  called  the  local  bloodlessness  "  local 
syncope."  But  the  patients  are  often  anemic  and  have  feeble  hearts, 
and  so  are  liable  to  fainting.  Hence  it  is  difficult  to  understand,  in 
reading  the  accounts  of  some  writers,  whether  they  are  alluding  to  the 

1  France  Med.,  1881,  t.  xxviii.,  p.  221. 

2  New  Sydenham  Society,  1888,  vol.  121.  Raynaud's  two  essays  on  local  asphyxia, 
translated  by  T.  Barlow. 

3  Lancet,  1896,  vol.  ii.,  p.  875. 

*  Am.  Jour.  Med.  Set.,  1896,  vol.  cxii.,  p.  522. 


GANGRENE  FROM  OBSTRUCTION  TO    CAPILLARIES,   ETC.      23 1 

local  spasm  in  a  limb,  or  to  syncope  produced  by  an  insufficient  blood- 
supply  to  the  brain. 

Symptoms. — The  earliest  of  the  Raynaud's  symptoms  is  the  dead 
white  finger ;  less  commonly  the  toes,  the  tips  of  the  ears,  or  the  end 
of  the  nose  are  affected.  The  finger  is  cold,  bloodless,  yellowish  white, 
insensitive  and  powerless.  The  attacks  occur  at  meal-times  and  during 
digestion,  whilst  getting  up  in  the  morning,  and  also  when  tired.  The 
spasm  is  followed  by  relaxation,  venous  congestion,  and  warmth.  The 
color  is  then  lilac  or  slaty  blue,  and,  if  the  fingers  are  put  into  hot 
water,  becomes  almost  black.  During  the  reaction  there  are  pains 
described  as  stinging,  burning,  and  shooting ;  occasionally  the  affected 
fingers  are  covered  with  a  cold  sweat  and  patches  of  red  congestion  ; 
erythromelalgia  or  red  neuralgia  and  patches  of  edema  occur.  The 
attacks  are  not  always  worst  in  winter,  but  often  in  spring  and  autumn. 
One  of  Raynaud's  cases  suffered  most  during  the  heat  of  summer, 
when  working  in  the  sun. 

When  gangrene  threatens,  recovery  is  incomplete  between  the 
paroxysms,  the  skin  becomes  hard  like  parchment,  the  color  becomes 
drab  or  bronzed,  gradually  violet,  and  finally  black.  The  local  venous 
congestion  must  be  distinguished  from  the  congenital  blue  of  morbus 
caeruleus,  consequent  on  a  patent  cardiac  septum.  A  case  is  recorded 
in  which  cyanosis  from  this  cause  was  later  on  complicated  by  Ray- 
naud's gangrene. 

Small  blisters  with  a  seropurulent  fluid  may  form.  There  may  be 
excoriation  and  desquamation  of  the  skin.  Raynaud's  gangrene  has 
occurred  in  several  cases  along  with  scleroderma ;  sometimes  one  has 
appeared  first,  sometimes  the  other  (Chauffard,1  Hutchinson  2).  Parox- 
ysmal attacks  of  hemoglobinuria  and  of  purpura  have  complicated 
Raynaud's  gangrene.  Cases  have  died  of  apoplexy  and  of  uremia 
where  the  pulse  has  previously  been  of  high  tension  and  the  arteries 
hypertrophied. 

As  regards  the  treatment  of  Raynaud's  symptoms  threatening 
gangrene,  the  anemia  is  treated  by  iron  and  arsenic ;  quinin  also  has 
acted  well  as  a  tonic,  especially  where  the  patient  has  had  ague.  The 
local  treatment  consists  in  shampooing  with  warm  salt  water.  The 
paroxysms  are  relieved  by  warm  water,  but  are  made  worse  by  hot 
water;  sometimes  cold  gives  more  relief,  but  it  should  be  applied  for  a 
short  time  only.  Opium  may  be  given  for  pain.  The  patient  should 
be  protected  against  cold,  as  mentioned  under  the  head  of  Frost-bite. 
Separation  is  allowed  to  go  on  spontaneously,  any  cutting  away  being 
confined  to  the  dead  part. 

V.  GANGRENE  FROM  OBSTRUCTION  TO  CAPILLARIES  AND  SMALL 

VEINS. 

The  feature  characteristic  of  this  class  of  gangrene  is  the  obstruc- 
tion to  the  blood-flow  through  the  capillaries  and  venules,  although 
the  tendency  to  gangrene  may  be  indefinitely  increased  by  failure  of 
the  general  circulation,  by  obstruction  to  the  main  artery,  or  by  pre- 

1  Gaz.  des  Hop.,  1895,  t.  lxviii.,  p.  818. 

2  Archives  of  Surgery,  1896,  vol.  vii.,  p.  201. 


232  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

viously  existing  arteriosclerosis.  The  capillaries  and  small  veins  are 
obstructed  as  a  direct  result  of  the  injury,  simple  traumatic  gangrene, 
or  by  an  inflammatory  septic  thrombosis,  which  may  appear  as  a  com- 
plication and  extension  of  the  former,  spreading  traumatic  gangrene. 

Simple  Traumatic  Gangrene. — A  burn  chars  the  tissues  and 
stops  the  circulation.  A  crush  smashes  the  tissues  and  produces  an 
extravasation  of  blood  which  compresses  and  arrests  the  blood-flow  in 
vessels  not  directly  injured.  A  bullet  entering  through  a  small  hole 
causes  a  destruction  of  tissue  and  an  extravasation  of  blood  depending 
upon  its  velocity  and  the  size  of  the  blood-vessels  met  with.  The 
modern  rifle  bullet  of  high  velocity  may  produce  an  "  explosive  "  effect, 
widely  smashing  and  destroying  the  tissues  in  its  course.  As  a  further 
consequence  of  severe  injury,  the  general  circulation  is  weakened  by 
shock  and  by  loss  of  blood. 

Treatment. — On  careful  examination  of  the  threatened  part,  the 
circulation  may  be  found  absolutely  stopped.  Even  when  incisions 
are  made  into  it,  there  is  no  oozing  from  the  cut  arteries.  The  treat- 
ment consists  in  removing  the  dead  part  as  soon  as  the  patient  has 
recovered  a  little  from  the  shock  of  the  accident,  and  before  decom- 
position has  set  in. 

Whenever  it  is  found  that  the  threatened  part  is  still  connected  with 
the  rest  by  some  uninjured  tissue,  it  is  always  possible  that  an  anasto- 
motic circulation  may  be  set  up  as  the  general  circulation  recovers 
from  the  shock  of  the  accident.  At  the  same  time  it  is  necessary  to 
remove  any  compression  on  the  still  unimpaired  vessels  by  turning 
out  extravasated  blood-clots,  by  reducing  fractures  and  dislocations, 
and  removing  foreign  bodies.  All  septic  material  should  be  removed 
from  the  wound.  As  soon  as  possible  after  the  accident  the  patient  is 
to  be  laid  at  rest,  hot  fluid  food  or  enemata  are  administered,  and  he  is 
well  covered  up  with  blankets  and  hot-water  bottles  until  he  becomes 
warm  and  begins  to  sweat.  A  burn  is  covered  with  dry  antiseptic 
dressings,  and  as  soon  as  the  dead  tissue  can  be  distinguished  from  the 
living,  the  former  is  cut  away,  or  it  is  partly  raised  and  strips  of  iodo- 
form gauze  are  slipped  beneath,  so  as  to  protect  the  living  tissue  from 
the  products  of  decomposition  of  the  dead  tissue.  In  the  case  of  a 
compound  fracture  or  bullet-wound,  the  area  of  injury  is  fully  exposed 
under  an  anesthetic,  the  skin  orifice  being  extended  by  incisions  as 
necessary.  All  the  pockets  are  cleared  of  blood-clot ;  foreign  bodies, 
bullets,  etc.,  are  removed;  splinters  are  replaced  in  position,  and  the 
fractured  ends  of  bones  and  dislocated  joints  reduced  and,  if  necessary, 
fixed  by  sutures  or  pegs.  Every  part  of  the  wound  is  freely  swabbed 
by  5  per  cent,  carbolic  acid  or  other  antiseptic,  the  antiseptic  being 
finally  swilled  away  by  pure  water.  If  the  hemorrhage  has  had  to  be 
controlled,  the  tourniquet  is  now  released  and  all  the  bleeding  points 
ligated.  One  or  more  strips  of  gauze  are  laid  in  the  wound  to  act 
as  a  drain,  and  the  limb  is  wrapped  up  and  placed  in  a  position  favor- 
able for  the  return  of  venous  blood,  which  must  not  be  hindered  by  a 
tight  bandage.  With  this  treatment  soon  after  the  injury  there  is  no 
danger  of  spreading  gangrene.  The  removal  of  causes  of  compres- 
sion allows  collateral  circulation  through  the  still  uninjured  vessels. 
Even  if  gangrene  should  happen,  the  delay  is  not  dangerous,  owing  to 


GANGRENE   FROM  OBSTRUCTION  TO   CAPILLARIES,    ETC.       2^$ 

the  antiseptic  treatment  applied  to  the  wound.  The  patient  will  be 
better  able  to  stand  the  amputation,  and,  if  the  circulation  returns  in 
part,  the  secondary  amputation  may  be  more  limited  than  would  have 
been  the  primary  one. 

In  old  people  the  circulation  is  often  poor,  owing  to  previous  arterio- 
sclerosis, and  so  in  them  gangrene  is  more  likely  to  follow  an  injury. 
They  may  be  less  able  to  undergo  the  strain  of  the  repair  of  an  injury 
than  that  of  the  amputation.  Moreover,  the  loss  of  the  limb  may  not 
be  so  important  as  to  a  younger  patient.  These  latter  considerations 
will  point  toward  primary  amputation  for  old  people.  Primary  ampu- 
tation may  still  have  to  be  largely  adopted  in  war-time,  when  the  means 
of  treating  the  wounded  are  of  an  inferior  kind.  In  amputating  for 
traumatic  gangrene  the  state  of  the  skin-flaps  requires  attention,  for 
although  the  level  of  amputation  be  above  the  injury  to  the  main 
blood-vessel,  if  the  skin  from  which  the  flaps  are  cut  has  been  bruised, 
sloughing  may  take  place.  Only  strong  patients  can  be  expected  to 
survive  sloughing  of  flaps  and  reamputation.  If,  therefore,  when  cut- 
ting the  flaps  the  small  vessels  are  found  already  thrombosed,  a  higher 
level  should  be  selected. 

Septic  or  Inflammatory  Gangrene. — The  characteristic  feature 
of  this  variety  of  gangrene  is  the  obstruction  of  the  capillaries  and  the 
small  veins  of  the  tissues  by  thrombi  containing  micro-organisms  which 
rapidly  multiply  and  spread  the  thrombosis,  and  so  the  gangrene. 
Anthrax  bacilli  multiply  at  the  site  of  the  inoculation,  and  the  capil- 
laries and  veins  become  blocked  by  masses  of  bacteria.  An  eschar 
forms  at  the  center,  and  around  it  is  an  inflammatory  zone  in  which  the 
thrombosis  is  going  on,  although  the  arterial  circulation  is  not  yet  at  a 
standstill.  Similarly,  a  boil  or  carbuncle  commences  by  a  septic  throm- 
bosis at  the  center,  which  causes  an  arrest  of  the  circulation  and  a 
central  slough  surrounded  by  an  inflammatory  zone. 

As  to  the  cause  of  septic  gangrene,  virulent  streptococci,  generally 
mixed  with  staphylococci,  are  the  organisms  commonly  found. 

Emphysematous  Gangrene. — Gaseous  abscesses  and  emphy- 
sematous gangrene,  in  which  foul  gas  is  present  from  the  commence- 
ment, not  secondarily  to  the  decomposition  of  tissue,  have  recently 
received  attention.  The  difficulties  lying  in  the  way  of  identifying  a 
specific  organism  as  the  actual  cause  of  the  emphysematous  gangrene 
have  been  due  to  the  simultaneous  presence,  in  particular,  of  strepto- 
cocci. Further,  on  isolating  and  producing  a  pure  culture  of  the  gas- 
forming  organisms,  they  have  been  found  but  feebly  pathogenic — e.g., 
producing  at  the  site  of  inoculation  merely  a  fugitive  edema,  unless 
the  general  or  local  resistance  of  the  animal  were  beforehand  artificially 
lowered.  When  found  in  man  unaccompanied  by  streptococci,  the 
part  affected  by  gangrene  has  generally  undergone  previously  some 
pathologic  changes,  the  results  of  an  injury  or  of  vascular  disease. 
In  a  number  of  patients  much  exhausted  from  various  causes,  gaseous 
abscesses  and  emphysematous  gangrene  have  followed  the  subcutane- 
ous injection  of  drugs.  No  gas-forming  bacillus  has  as  yet  fulfilled  the 
postulates  required  by  Koch  to  prove  it  to  be  the  actual  cause  of  the 
gangrene. 

The  organism  noted  as  occurring  in  such  cases  was  the  "  Vibrion 


234  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

septique  "  of  Pasteur,  by  subsequent  observers  termed  the  bacillus  of 
malignant  edema.  Hut  the  large  number  of  observations  made  by 
Welch  *  have  clearly  proved  that  gaseous  abscesses  and  emphysema- 
tous gangrene  are  most  frequently  associated  with  the  presence  of  the 
anaerobic  organism  first  described  by  him  in  1891,  and  termed  the 
Bacillus  aerogenes  capsulatus. 

Guinea-pigs,  pigeons,  and  sparrows  inoculated  with  quite  fresh  cul- 
tures may  develop  a  local  necrosis  of  tissue  with  the  formation  of  gas, 
and  may  even  die.  Rabbits  and  mice  are  more  resistant  without  being 
quite  immune.  A  gaseous  abscess  may  be  produced  around  the  frac- 
tured ends  of  a  bone  by  inoculating  a  rabbit  intravenously.  Such  an 
intravenous  injection  may  not  do  much  harm  to  an  uninjured  rabbit; 
but  if  the  animal  be  killed  a  few  minutes  after  the  intravenous  injection 
and  be  then  kept  warm  for  some  hours,  an  abundant  production  of  gas 
will  be  found  to  have  taken  place  in  the  blood,  organs,  and  tissues. 
However,  fresh  cultures  differ  widely  in  virulence,  and  older  ones  pre- 
sent but  slight  virulence,  or  none  at  all.  The  natural  habitat  of  the 
organism  is  in  the  alimentary  canal  and  in  the  soil,  whence  the  origin 
of  the  various  infections  can  be  easily  traced. 

Very  much  less  often  the  aerobic  organism,  the  bacillus  of  malig- 
nant edema,  noted  by  Sanfelice,  Klein,  and  others,  is  the  one  found,  but 
practically  always  in  man,  mixed  with  streptococci.  It  was  obtained 
by  the  injection  of  garden  mould.  But  pure  cultures,  when  inoculated 
into  animals,  produce  only  a  transient  edema  without  either  gangrene  or 
emphysema,  unless,  as  before  mentioned,  the  resistance  of  the  animal 
be  first  artificially  lowered.2 

Spreading  Traumatic  Gangrene. — The  amount  of  injury  varies 
from  a  mere  prick  or  scratch  up  to  an  extensive  laceration,  but  the 
essential  feature  is  the  septic  inoculation.  In  some  cases  the  injury 
may  be  so  slight  as  a  prick  from  a  thorn,  a  scratch  from  an  instru- 
ment, the  sting  of  an  insect,  or  the  inoculation  of  septic  material 
through  a  previous  abrasion.  In  other  cases  there  may  be  a  serious 
contusion,  a  compound  fracture,  a  gunshot  wound,  the  bite  of  an  ani- 
mal, a  crush  by  machinery  or  on  the  railway,  and  the  septic  inoculation 
is  then  a  complication  of  a  lacerated  wound. 

Symptoms. — The  marked  sign  of  spreading  traumatic  gangrene  is 
advancing  dusky  edema.  Within  a  day  of  the  accident  the  edema  may 
have  spread  from  the  injured  hand  or  foot  to  the  forearm  or  leg  ;  in  two 
days  or  so  it  may  have  almost  reached  the  shoulder-  or  hip-joint.  The 
patient  is  meanwhile  much  affected  by  septic  absorption,  soon  becomes 
delirious,  and  has  a  rapid  pulse  and  respiration.  The  temperature  is 
untrustworthy :  it  may  be  high  at  first  and  then  slowly  descend  to  be 
little  above  the  normal,  or  it  may  even  become  subnormal  when  the 
patient  is  exhausted.  Commencing  gangrene  is  shown  by  the  bullae 
containing  stinking  greenish  serum  which  form  on  the  dusky  edema- 
tous skin.  On  separation  of  the  epidermis,  the  dermis  beneath  appears 
of  a  greenish  yellow.  The  skin  crackles  when  touched,  owing  to  septic 
emphysema.  On  cutting  into  the  limb,  abscesses  containing  stinking 
pus  and  gas  are  found  in  all  directions.     Within  two  days  the  gan- 

1  "The  Shattuck  Lecture  on  Morbid  Conditions  Caused  by  Bacillus  Aerogenes  Capsu- 
latus," Bulletin  of  the  Johns  Hopkins  Hospital,  1901,  September,  p.  185. 

2  See  Corner  and  Singer,   Trans.  Pathological  Society,  London,  1901,  vol.  lii.,  p.  42. 


GANGRENE   FROM  OBSTRUCTION    TO   CAPILLARIES,    ETC.     235 

grene  may  have  extended  from  the  hand  or  foot  to  the  elbow  or  knee. 
Very  soon  the  septic  edema  spreads  from  the  limb  to  the  trunk,  and 
behind  it  follows  the  gangrene. 

The  only  treatment  is  prompt  amputation  above  the  edematous 
zone,  and  removal  of  the  arm  at  the  shoulder-joint  or  of  the  leg  high 
up  in  the  thigh  has  saved  life  in  many  cases.  If  the  flaps  are  at  all 
affected  by  dusky  edema  or  by  septic  thrombosis,  this  will  be  perceived 
in  cutting  them.  If  there  is  some  edema  and  it  be  deemed  inexpedient 
or  impossible  to  cut  a  flap  higher  up,  iodoform  gauze  should  be  laid  in 
the  wound,  between  the  flaps,  and  then  a  limited  ulceration  of  the  flaps 
will  not  so  greatly  affect  the  patient.  If  after  such  dressings  the  flaps 
become  quite  healthy,  secondary  sutures  may  be  used.  The  adminis- 
tration of  streptococcus-antitoxin  may  be  of  advantage  as  an  adjuvant 
to  the  surgical  measures,  but  only  when  streptococci  are  the  chief 
organisms  found  (Steele !).  In  early  and  limited  cases  free  incisions, 
the  limb  being  afterward  kept  in  a  hot  boracic  bath,  may  serve  to 
arrest  the  gangrene. 

Cutaneous  Gangrene. — This  form  of  gangrene  is  set  up  by  the 
micro-organisms  causing  erysipelas,  or  similar  streptococci,  in  patients 
previously  weakened  by  disease.  An  acute  attack  of  erysipelas  may 
go  on  to  gangrene  of  the  skin,  especially  of  the  scrotum.  Infants  and 
children  who  have  suffered  from  one  of  the  specific  fevers  are  liable  to 
be  attacked,  multiple  patches  of  gangrene  developing  on  the  skin, 
especially  of  the  abdomen.  The  patients  have  generally  been  much 
exhausted,  and  there  is  great  failure  of  the  circulation.  Yet  some  of 
the  worst  cases  of  multiple  cutaneous  gangrene  have  followed  chicken- 
pox  in  which  the  child  has  suffered  beforehand  but  slightly.  In  old 
people,  multiple  gangrenous  patches  may  appear  when  many  of  the 
vessels   have  been  partly  obstructed  by  arteriosclerosis. 

Symptoms. — The  first  sign  of  cutaneous  gangrene  is  a  red  blush 
with  slight  inflammatory  induration.  The  color  quickly  becomes 
dusky  and  ceases  to  disappear  on  pressure  ;  sensation  is  lost,  and  the 
patch  soon  becomes  gangrenous.  Several  of  these  patches  appear 
simultaneously,  or  one  after  the  other  within  a  day  or  two. 

Treatment. — The  only  specific  general  treatment  is  the  injection  of 
antistreptococcic  serum,  and  the  more  clear  the  erysipelatous  origin, 
the  more  likely  the  success.  Locally  an  erysipelatous  patch  may  be 
painted  with  iodin  or  nitrate  of  silver,  with  the  view  of  increasing  the 
circulation  by  counter-irritation  and  so  preventing  thrombosis.  When- 
ever thrombosis  and  loss  of  sensation  preindicate  gangrene,  the  skin 
should  be  raised  by  an  incision  and  a  strip  of  gauze  slipped  beneath. 
This  gives  any  skin  in  which  some  circulation  is  still  going  on  the  best 
chance  of  recovery,  while  it  anticipates  the  collection  of  foul  pus 
beneath  the  slough.  As  soon  as  the  outline  of  the  slough  is  deter- 
mined, it  is  cut  away. 

Cancrum  Oris ;  Noma  of  the  Vulva ;  Gangrene  of  the 
Umbilicus. — Children  exhausted  by  scarlet  fever,  measles,  and  other 
specific  fevers,  by  bronchopneumonia  or  general  neglect,  are  liable  to  be 
attacked  by  gangrene  which  commences  in  the  mucous  membrane  of 
the  mouth,  on  the  vulva  in  female  children,  and  at  the  umbilicus  of 

1  Brit.  Med.  Jour. ,  1896,  vol.  ii.,  p.  1768. 


236  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

infants.  It  is  distinguished  from  the  cutaneous  gangrene  by  rapidly 
burrowing  into  the  deeper  structures,  and  by  commencing  in  some 
excoriation  or  ulcer.  The  onset  is  insidious,  there  being  only  a  small 
superficial  slough,  beneath  which  the  septic  thrombosis  and  gangrene 
rapidly  go  on.  Moreover,  the  child  does  not  complain  of  pain,  does 
not  cry,  and  the  appetite  persists.  It  becomes  more  and  more  dull  and 
sleepy,  without  any  marked  rise  of  temperature,  then  delirious,  and  the 
pulse' and  respiration  increase  in  rate.  The  first  sign  to  attract  atten- 
tion is  often  the  foul  smell ;  then  a  grayish  patch  will  be  found,  sur- 
rounded by  a  brawny  zone.  On  exploration,  stinking  sloughs  are 
brought  to  light.  In  cancrum  oris  the  cheek  may  be  rapidly  per- 
forated or  destroyed,  the  lower  jaw  becomes  necrosed ;  or  the  upper 
jaw  may  be  similarly  affected  and  the  antrum  filled  with  pus.  The 
swelling  of  the  cheek,  in  the  absence  of  striking  symptoms,  may  be  at 
first  mistaken  for  alveolar  abscess.  The  child  may  die  of  septicemia, 
or  develop  septic  pneumonia,  or  the  gangrene  may  spread  to  the  neck 
first. 

Noma  may  extend  rapidly  on  the  vulva,  causing  a  deep  sloughing 
ulcer,  which  spreads  toward  the  pubes,  bladder,  or  rectum.  A  similar 
form  of  gangrene  is  occasionally  seen  in  the  scrotum  of  little  boys. 

Gangrene  of  the  umbilicus  is  common  amongst  the  poor  of  hot  cli- 
mates ;  it  rapidly  extends  to  involve  the  whole  thickness  of  the  abdomi- 
nal wall,  and  finally  the  peritoneum,  if  the  infant  lives  long  enough. 

Treatment. — The  occurrence  of  such  cases  is  prevented  by  care 
during  convalescence,  by  attention  to  thrush  or  carious  teeth.  System- 
atic cleanliness  is  required  to  avoid  excoriations  about  the  umbilicus 
and  genitals.  Immediately  cancrum  oris  is  recognized  by  the  foul 
smell,  grayish  slough,  and  brawny  induration,  active  treatment  must  be 
adopted.  A  little  chloroform  is  generally  given,  unless  there  is  marked 
drowsiness,  when  chloroform  is  not  only  superfluous  but  dangerous. 
The  head  must  hang  low,  so  that  no  slough  may  be  inhaled,  and  the 
mouth  well  opened  by  a  gag.  Then  as  much  as  possible  of  the  slough 
is  cut  or  scraped  away  until  vascular  tissue  is  reached,  without  going 
far  enough  to  excite  severe  hemorrhage.  This  may  include  the  re- 
moval of  the  alveolar  portion  of  the  upper  or  lower  jaw,  if  it  is  dead. 
Then  the  walls  of  the  cavity  left  by  removing  the  slough  are  scrubbed 
with  pure  carbolic  acid  or  0.5  per  cent.  (2  :  1000)  perchlorid  of  mer- 
cury. Care  should  be  taken  not  to  use  an  excess  of  the  antiseptic,  to 
guard  the  throat  by  a  sponge  on  a  holder,  and  to  keep  the  head  low. 
All  the  antiseptic  is  finally  washed  away  with  water.  The  actual  cau- 
tery may  be  used  instead,  merely  searing,  not  charring,  living  tissue. 
There  is  no  need  to  apply  fuming  nitric  acid,  since  its  application  is 
much  more  difficult,  and  it  penetrates  deeply  and  causes  more  pain 
without  being  more  efficacious  than  the  carbolic  acid  or  sublimate.  A 
gangrenous  patch  involving  the  tonsil  of  a  child  was  checked  at  once 
by  applying  pure  carbolic  acid.  Frequent  irrigation  with  permanganate 
of  potash  is  used,  along  with  iodoform  gauze  as  a  dressing.  Alter- 
nately, cavities  are  filled  with  gauze  saturated  with  1  or  2  per  cent, 
of  the  permanganate.  Portions  of  the  lost  jaw  may  be  later  on 
replaced  by  new  bone  ;  a  perforated  cheek,  or  one  in  which  the  jaw 
tends  to  become  closed  by  the  contracture  of  scar-tissue,  is  repaired  by 


GANGRENE   FROM  OBSTRUCTION  TO    CAPILLARIES,    ETC.     237 

plastic  operations.  Gangrene  of  the  vulva  may  lead  to  severe  hemor- 
rhage, necrosis  of  the  pubes,  etc.  It  is  treated  as  above,  the  resulting 
cavity  being  well  plugged.  An  infant  is  not  likely  to  survive  gangrene 
of  the  umbilicus,  but  it  should  be  treated  promptly,  in  the  way  above 
described,  to  prevent  perforation  of  the  peritoneum. 

Phagedena — Hospital  Gangrene  (see  Chapter  VII.). — This  form 
of  infectious  gangrene  is  now  most  frequently  seen  as  a  complication  of 
venereal  disease  and  of  ulcerated  legs,  and  is  under  the  former  circum- 
stances transmitted  by  direct  inoculation.  The  glans  maybe  destroyed, 
or  a  part  or  whole  of  the  penis,  and  the  skin  of  the  scrotum.  It  may 
extend  back  through  the  perineum  and  perforate  the  rectum.  In  the 
female  it  may  spread  to  the  bladder.  If  it  attacks  a  suppurating  bubo, 
the  ulcer  may  quickly  perforate  into  the  large  blood-vessels.  A 
phagedenic  ulcer  of  the  leg  commences  to  extend  rapidly  round  the 
leg  and  excavate  more  deeply,  so  as  to  expose  the  bone. 

Phagedena  is  probably  caused  by  a  special  bacillus  inoculable  on 
human  beings.1  The  surface  of  a  wound  becomes  covered  with  gray- 
ish-green sloughs  and  stinking  pus.  It  is  often  a  mixed  infection,  ery- 
sipelatous gangrene  rapidly  extending  in  the  neighboring  skin  and 
tissues. 

If  phagedena  is  threatening,  the  sore  should  be  painted  with  pure 
carbolic  acid.  In  a  marked  and  extending  case  the  patient  is  anesthe- 
tized, and  all  the  slough  scraped  away.  Then  pure  carbolic  acid  is 
well  rubbed  in  ;  finally  all  the  carbolic  acid  is  washed  away  with  pure 
water.  The  pure  carbolic  acid  will  arrest  the  phagedena  at  once ;  it 
does  not  penetrate  the  healthy  tissues,  and  owing  to  its  analgesic  prop- 
erties causes  little  pain.  Caustics  like  nitric  acid,  caustic  potash,  arsenic, 
or  chlorid  of  zinc  are  difficult  to  limit  and  give  much  pain.  The  actual 
cautery  may  be  used,  as  it  can  be  exactly  applied ;  but  it  should  sear, 
not  char.  The  ulcer  is  dressed  with  iodoform  gauze,  with  gauze  wrung 
out  of  1  or  2  per  cent,  permanganate,  or  by  boric-acid  fomentations,  to 
which  opium  may  be  added  to  relieve  pain. 

Bed-sores,  or  Decubitus. — A  bed-sore  is  a  gangrenous  ulcer  to 
which  a  patient  whose  circulation  is  weak  is  liable  owing  to  continual 
pressure  and  to  the  irritation  of  the  skin  by  dirt  and  sweat.  It  is  nearly 
always  due  to  the  absence  of  proper  medical  attention  and  nursing. 
The  older  and  more  helpless  the  patient,  the  greater  the  liability  to 
bed-sores.  They  are  the  most  difficult  to  prevent  in  the  delirious,  the 
paralyzed,  and  the  insane.  Yet  no  bed-sore  of  an  extensive  kind  can 
be  looked  upon  as  inevitable.  Paralysis  due  to  injury  or  disease  of 
the  spinal  cord  is  not  necessarily  followed  by  bed-sores.  Public  infirm- 
aries and  asylums  now  record  the  number  of  bed-sores  which  occur, 
and,  owing  to  the  advance  in  the  standard  of  nursing,  the  number  of 
bed-sores  in  such  institutions  is  becoming  a  vanishing  quantity. 

Bed-sores  occur  on  the  sacrum  or  buttocks  owing  to  pressure  in 
the  dorsal  position,  over  the  great  trochanter  from  lying  on  the  side, 
over  the  anterior  iliac  spine,  knee,  dorsum  of  the  foot,  etc.,  from  the 
pressure  of  the  bed-clothes.  Bed-sores  are  seen  higher  up  on  the  spine 
or  between  the  shoulders  when  the  spine  is  curved  or  when  there  is  a 
ridge  in  the  bed.     Sores  may  be  seen  over  the  elbows  or  even  over  the 

1  Vincent  and  Cayon,  Annates  de  T  Institul  Pasteur,  1896,  t.  x.,  pp.  489,  661. 


238 


INTERNATIONAL     TEXT-BOOK   OF  SURGERY. 


occiput  from  unduly  resting  on  these  bony  prominences.  Sores  appear 
on  the  point  of  the  heel,  over  the  malleoli,  or  on  the  side  of  the  knee 
or  elbow  from  the  pressure  of  a  splint.  The  upper  end  of  the  splint 
may  press  on  the  patient's  buttocks,  into  his  fork,  or  into  his  armpit, 
and  so  cause  a  sloughing  sore. 

The  prevention  of  bed=sores  is  an  essential  part  of  good  nursing. 
The  bed  should  be  made  with  a  firm  smooth  mattress,  not  a  feather- 
bed ;  the  under  sheet  and  blanket  must  be  changed  before  they  are 
saturated  with  sweat.  The  draw*  sheet  is  spread  free  from  creases,  de- 
pressions, or  prominences,  and  foreign  bodies,  such  as  bread  crumbs, 
are  kept  out.  But  the  great  preventive  is  the  washing  of  the  places 
liable  to  pressure  with  hot  water,  soap,  and  flannel  or  sponge,  laving 
with  clean  water,  and  completely  drying  with  a  smooth  warmed  towel. 
Most  weakly  patients  confined  to  bed  require  such  a  washing  twice  a 
day,  and  it  may  have  to  be  done  much  oftener,  indeed,  every  three 
hours.  The  urine,  feces,  and  discharges  from  wounds  should  be  ab- 
sorbed before  the  bed  is  soiled.     The  urine  of  a  man  can  be  received 


Fig.  52. — Bed-sores  in  a  case  of  fracture  of  the  spine. 

into  a  flask-shaped  urinal,  that  of  a  little  boy  into  a  smaller  vessel,  such 
as  a  large  test-tube.  Urine  coming  through  a  perineal  wound  or  from 
a  female  with  incontinence  is  received  into  a  pad  of  wool  or  compressed 
moss,  which  must  be  changed  before  it  is  saturated.  Incontinence  of 
urine  maybe  much  relieved  by  aseptic  catheterism  and  irrigation  of  the 
bladder.  The  feces  should  be  removed  as  soon  as  passed,  by  anticipating 
the  patient's  need  for  the  bed-pan,  by  regulating  the  bowels  with  aperients, 
by  administering  a  cleansing  enema  daily  to  remove  scybala,  and,  when 
there  is  complete  incontinence,  by  frequently  changing  the  pad  receiv- 
ing them.  As  supplements  to  hot  soap  and  water,  but  by  no  means  as 
substitutes,  turpentine  or  ether  may  be  used  to  aid  in  removing  excess 
of  sweat  and  dirt ;  lotions  of  lead  acetate,  of  zinc  chlorid,  of  silver 
nitrate,  or  of  spirit  harden  the  skin.  After  complete  drying,  a  dusting 
powder  of  zinc  oxid  and  starch  may  be  applied,  but  irritating  cakes 
will  form  if  there  is  any  moisture. 

A  prostrate  patient  requires  to  be  frequently  turned  to  one  side  or 
the  other;  young  people  may  be  even  turned  on  to  the  face.     Pressure 


GANGRENE   FROM   OBSTRUCTION   TO    CAPILLARIES,    ETC.      239 

is  also  taken  off  by  pillows,  air-cushions,  and  water-beds  of  various 
kinds. 

The  surgeon  also  has  to  direct  his  attention  to  avoiding  bed-sores. 
He  has  to  see  that  the  nurse  is  assisted  in  turning,  lifting,  and  cleaning 
the  patient,  especially  when  he  is  heavy,  and  an  arrangement  with  pul- 
leys may  be  needed.  The  surgeon  must  also  modify  his  treatment  of 
the  patient  with  this  object ;  ill-fitting  plaster  jackets  or  splints  should 
be  changed ;  a  child  with  hip-joint  disease  must  have  both  legs  fixed 
on  side-splints  (Hamilton's)  sufficiently  wide  apart  to  be  easily  cleaned  ; 
an  old  woman  with  an  intracapsular  fracture  of  the  femur  should  be 
got  up  into  a  chair  in  spite  of  there  being  no   union. 

Signs  and  Treatment  of  a  Bed=sore. — The  skin  fails  to  quickly 
regain  its  normal  color  when  pressure  is  released.  Instead,  it  is  of  a 
dusky  red  which  does  not  disappear  under  the  finger  pressure;  the  skin 
feels  rigid  and  thicker  than  normal.  The  epidermis  becomes  detached, 
exposing  the  papillae.  At  this  stage  recovery  is  still  possible.  If  the 
unfavorable  conditions  persist,  the  skin  becomes  gangrenous.  If  the 
part  pressed  on  is  first  rendered  anemic,  the  slough  is  grayish  white ; 
if  there  is  beforehand  the  dusky  red  of  venous  congestion,  a  greenish 
slough  forms.  When  gangrene  has  not  definitely  set  in,  the  treatment 
above  noted  should  be  continued,  and  it  may  serve  to  limit  the  extent 
of  the  bed-sore.  But  when  the  skin  is  clearly  dead,  the  sooner  it  is 
cut  away  the  better,  after  which  the  sore  is  frequently  washed,  and 
dusted  with  iodoform  and  dressed  with  gauze.  Should  there  be  any 
sign  of  phagedena,  pure  carbolic  acid  may  be  painted  on.  The  fre- 
quent antiseptic  dressings  should  produce  a  healthy  granulating  sur- 
face, and  then  the  ulcer,  if  large,  may  be  covered  in  with  skin-grafts. 
If,  after  the  removal  of  the  sloughs,  granulations  are  slow  in  forming, 
astringent  lotions  may  be  used  to  hasten  the  process.  A  young  patient 
covered  by  numerous  sores  may  be  kept  immersed  in  a  bath  with  a 
swim-collar  round  his  neck.  The  water  requires  frequent  changing, 
and  permanganate  of  potash  or  boric  acid  may  be  added. 

Extensive  bed-sores  are  met  with  in  exhausted  patients.  If  not 
actively  treated,  the  ulceration  may  spread  to  the  spinal  meninges  and 
set  up  fatal  meningitis.  It  may  be  complicated  by  sloughing  of  the 
bladder,  septic  pneumonia,  etc. 


CHAPTER    X. 
SURGICAL  TUBERCULOSIS. 

Definition. — Tuberculosis  has  been  defined  to  be  (Watson  Cheyne) 
"an  infective  disease  due  to  the  growth  in  the  tissues  of  a  parasitic 
micro-organism, the  tubercle  bacillus."  {Vide  Chap.  I.)  Its  histological 
characteristic  is  a  tissue  of  new  formation,  occurring  in  either  a  nodu- 
lar form  (the  classic  tubercle)  or  as  a  diffuse  infiltration  (Nelaton),  in 
which  are  found  the  essential  "  epithelioid  cells,"  combined  or  not  with 
"  giant  cells."  This  new  tissue  presents  a  marked  tendency  to  undergo 
a  special  form  of  degeneration — anemic  and  coagulation-  or  toxin- 
necrosis — termed  caseation,  and  to  excite  a  chronic  form  of  inflam- 
mation around  it. 

Frequency. — In  former  times  the  subject  of  tuberculosis  was  com- 
monly relegated  to  the  physician  ;  but,  since  the  establishment  of  the 
identity  of  scrofula  and  tuberculosis,  the  ravages  of  the  tubercle 
bacillus  furnish  to  the  modern  surgeon  at  least  one-quarter  of  his 
work. 

Incidence. — Almost  every  organ  of  the  body  may  be  invaded  by 
tubercle ;  but  in  some  its  frequency  is  great,  while  in  others  it  occurs 
but  rarely.  Amongst  the  former  may  be  mentioned  the  lymph-glands, 
the  brain  and  its  envelopes,  the  lungs,  pleurae,  and  peritoneum,  the 
bones,  joints,  and  testicles  ;  and  amongst  the  latter  the  muscles,  ovaries, 
pancreas,  and  the  thyroid  gland.  While  the  Bacillus  tuberculosis  con- 
stitutes the  seed  of  the  disease,  a  special  "  abnormal  vulnerability " 
(Virchow)  of  the  lymphatic  tissue  affords  a  favorable  soil  for  its  fruition. 
This  is  the  body  state  described  by  the  older  writers  as  the  strumous 
or  scrofulous  diathesis,  a  state  which  may  be  either  inherited  or 
acquired.  This  same  state  likewise  increases  the  susceptibility  of  the 
system  to  other  infections  than  the  tuberculous,  such  as  the  syphilitic 
and  the  so-called  zymotic.  Different  physical  types  have  been  ingeni- 
ously described  as  associated  with  this  condition.  They  are  two — the 
fair  and  the  dark ;  and  usually  each  of  these  presents  two  varieties — 
the  fine  or  sanguine,  and  the  coarse  or  phlegmatic.  In  the  late  Sir 
John   Erichsen's  text-book  they  are  thus  briefly  and  well  described : 

"  The  most  common  is  that  which  occurs  in  persons  with  fair,  soft,  and  transparent  skins, 
having  blue  eyes  with  large  pupils,  light  hair,  tapering  fingers,  and  fine  white  teeth  ;  whose 
beauty,  indeed,  is  often  great,  especially  in  early  life,  being  dependent  rather  on  roundness  of 
outline  than  grace  of  form,  and  whose  growth  is  rapid  and  precocious.  In  these  individuals 
the  affections  are  strong  and  the  procreative  power  considerable  ;  the  mental  activity  is  also 
great,  and  is  usually  characterized  by  much  delicacy  and  softness  of  feeling,  and  vivacity 
of  intellect.  Indeed,  it  would  appear  that  in  such  persons  as  these,  the  nutritive,  the  pro- 
creative,  and  the  mental  powers  are  rapidly  and  energetically  developed  in  early  life,  but 
become  proportionately  early  exhausted.      Cito  maturus,  cito  putridtts. 

"  In  another  variety  of  the  fair  scrofulous  temperament  we  find  a  coarse  skin,  short  and 
rounded  features,  light  gray  eyes,  crisp  and  curly  sandy  hair,  and  short  and  somewhat 
ungainly  stature,  and  club  fingers  ;  but  not  uncommonly,  as  in  the  former  variety,  great  and 
240 


SURGICAL    TUBERCULOSIS.  24 1 

early  mental  activity,  and  occasionally  much  muscular  strength.  In  the  dark  form  of  scrof- 
ulous temperament  we  usually  find  a  more  heavy,  sullen,  and  forbidding  appearance  ;  a  dark, 
coarse,  sallow  or  grayish-looking  skin  ;  short,  thick,  and  harsh  curly  hair  ;  a  small  stature, 
but  often  a  powerful  and  strong-limbed  frame  ;  with  a  certain  degree  of  torpor  or  languor 
of  the  mental  faculties,  though  the  powers  of  the  intellect  are  remarkably  developed.  The 
other  dark  strumous  temperament  is  characterized  by  clear,  dark  eyes,  fine  hair,  sallow 
skin,  and  by  a  mental  and  physical  organization  that  closely  resembles  the  first-described 
variety  of  the  fair  strumous  diathesis." 

Sir  Frederick  Treves  regards  the  members  of  the  sanguine  type  as 
those  who  have  inherited  the  condition  ;  the  phlegmatic  as  having 
acquired  it  from  the  neglect  of  hygiene  in  their  environment. 

Age. — All  periods  of  life  are  subject  to  tuberculosis,  but  the  inci- 
dence of  the  surgical  aspect  of  the  affection  is  largely  in  childhood,  the 
strumous  glands  and  bone  and  joint  affections  occurring  most  fre- 
quently, though  by  no  means  exclusively  in  this  period.  The  other 
extreme  of  life  also  manifests  a  liability  to  the  affection,  and  "senile 
tuberculosis"  and  "senile  scrofula,"  which  are  now  interchangeable 
terms,  are  met  with  from  time  to  time.  The  affection  may  have  per- 
sisted or  remained  latent  from  early  life,  or  may  have  begun  de  novo. 
The  form  most  frequently  assumed  is  bone  or  tendon  disease  (fre- 
quently about  the  wrist,  when  the  well-known  pulmonary  association 
is  still  manifest);  but  cervical  glandular  enlargements  and  other  local- 
izations occur. 

Histology  of  Tubercle. — The  term  tubercle,  meaning  a  nodule, 
or  little  node,  has  in  former  times  been  applied  to  three  different 
stages  of  the  one  inflammatory  process,  and  thus  three  different  forms 
have  been  described.  The  crude  tubercle  was  the  name  applied  by 
Laennec  to  the  gross,  macroscopic  node  of  yellow  color  which  resulted 
from  the  caseation  of  many  coalesced  gray  nodules ;  while  each  gray 
nodule  visible  to  the  naked  eye,  and  having  approximately  the  appear- 
ance of  a  millet  seed  (milium)  while  newly  formed,  and  not  having 
undergone  fatty  disintegration  and  caseous  degeneration,  was  termed 
a  gray,  or  miliary,  tubercle.  The  microscope  soon  revealed  the  fact 
that  each  such  miliary  tubercle  was  composed  of  an  aggregation  of 
minute,  invisible,  gray,  translucent  masses  of  a  similar  character,  for 
the  designation  of  which  the  term  submiliary  tubercle  was  coined  ;  and 
for  which  the  histological  name  tubercle  should  be  reserved  to-day. 

The  tubercle  is  a  histological  entity  or  neoplasm  (infective  granu- 
loma) of  inflammatory  origin,  resulting  from  irritation  of  the  invaded 
tissue  cells  by  the  Bacillus  tuberculosis  or  its  toxins.  Virchow  origi- 
nally taught  that  its  starting  point  was  always  in  the  connective  tissue 
or  other  mesoblastic  structure  ;  but  experiment  upon  animals  has 
shown  that  "  the  cells  which  are  nearest  the  essential  microbic  cause, 
irrespective  of  their  embryological  origin,  their  histological  structure, 
or  their  physiological  function  "  (Senn),  are  the  seat  of  the  inflamma- 
tory proliferation.  Under  the  microscope  typical  tubercles  can  be 
demonstrated  to  consist  of  three  or,  perhaps,  four  constituent  elements 
— leukocytes,  epithelioid  cells,  giant  cells,  and  a  reticulum.  The  retic- 
ulum of  tubercle,  first  described  by  Wagner  and  Schiippel,  is  now 
regarded  by  most  authorities  as  simply  the  pre-existing  connective 
tissue,  invaded  and  pushed  aside  by  the  new  cells,  and  when  furnished 
with  blood-vessels  it  is  invariably  so.     But  in  some  cases  the  reticulum 


242 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY, 


seems  to  be  formed,  at  least  to  a  large  extent,  by  the  processes  of  the 
epithelioid  cells,  or,  as  Watson  Cheyne  claims,  may  be  simply  dif- 
fraction appearances  due  to  defective  illumination  of  the  specimens. 

As  the  cell-growth  is  most  active  at  the  center  of  the  mass,  and  a 
certain  pressure  is  thus  exerted  from  within  outward,  there  is  seen  at 
the  periphery  a  thickening  of  this  network,  amounting  at  times  almost 
to  the  formation  of  a  capsule  (Warren),  which  appearance  is  at  other 
times  due  to  the  endothelial  growth  occurring  within  the  vessel  whose 
wall  furnishes  the  seeming  fibrous  capsule.  The  reticular  fibers  are 
oftentimes  well  marked.     They  appear  to  radiate  from  the  margin  of 


pIG_  53. Portion  of  a  compound  nodule  from  a  tuberculous  testis.     Seminiferous  tubules 

with  spermatogenesis  arrested  beyond  division  of  the  spermatogonia.  Interstitial  cells  with 
crystalloids.  An  artery  in  transection  on  the  left.  Lymphoid  capsule  surrounding  the  whole 
nodule.  Giant  cell  with  its  processes ;  crescentically  arranged  nuclei,  its  necrotic  center.  Sur- 
rounding the  giant  cell  are  epithelioid  cells  and  a  few  lymphoid  cells  (nuclei  represented 
black).  Surrounding  the  giant  cell  and  epithelioid  cells  is  a  reticular  capsule  infiltrated  with 
lymphoid  cells.  Outside  the  reticular  capsule  are  epithelioid  cells  of  other  portions  of  the 
compound  nodule. 

the  central  giant  cell  or  cells,  and  to  assume  a  concentric  arrangement 
at  the  periphery  of  the  granule.  The  meshes  of  the  reticulum  are 
occupied  by  some  giant  cells,  epithelioid  cells,  and  lymphoid  corpuscles. 
The  whole  is  called  a  "  giant-cell  system." 

The  giant  cells  of  tubercle  {macrocytcs  of  Klebs)  differ  in  nowise 
from  those  found  elsewhere,  as  in  granulation-tissue,  gummata,  sarco- 
mata, the  placenta,  inflamed  serous  membranes,  actinomycosis,  and 
bone-marrow  (the  myeloplaques  of  Robin).  They  are,  probably,  simply 
overgrown  and  plethoric  cells  which,  by  virtue  of  their  ameboid  move- 


SURGICAL    TUBERCULOSIS. 


243 


ment,  have  succeeded  in  taking  up  more  than  their  share  of  the  sur- 
rounding pabulum  in  the  shape  of  fragmented  leukocytes.  They 
present  one  peculiarity,  however,  in  the  arrangement  of  their  nuclei, 
which  tend  to  take  up  a  position  in  the  periphery  of  the  cell  with  their 
long  axes  radiating  from  the  center ;  sometimes  they  are  "  huddled 
together  in  a  semilunar  cluster  at  one  end"  (Treves),  still  preserving, 
for  the  most  part,  however,  their  radiating  axial  arrangement.  Vacuoles 
or  necrotic  foci  are  of  frequent  occurrence  in  giant  cells.  Apparent 
vacuoles  may  result  from  faintly  stained  or  only  marginally  stained 
nuclei.  The  bacilli  of  tuberculosis,  abundant  enough  in  experimental 
tuberculosis,  but  much  less  numerous  in  human  pathology,  are  found 
within  the  giant  cell,  but  manifest  a  preference  for  its  peripheral  part, 
more  marked  as  central  degeneration  progresses.  This  central  degen- 
eration, called  caseation,  is  a  marked  characteristic  of  the  giant  cell,  and 
consists  in  an  anemic  or  toxic  coagulation-necrosis  of  the  protoplasm, 
which  has  a  strong  tendency  to  spread  throughout  the  cell,  and  from 
one  giant-cell  system  to  another,  and  thus  to  give  rise  to  coarse  cheesy 
masses  so  characteristic  of  the  tuberculous  process. 


Fig.  54. — Giant  cell  from  the  periphery  of  a  nodule  of  a  tuberculous  testis,  to  show  occa- 
sional grouping  of  the  nuclei  toward  the  end  of  the  cell.  Shows  giant-cell  processes  and 
reticular  fibers  passing  into  the  giant  cell ;  also,  periphery  of  the  caseating  area. 


In  the  absence  of  caseation,  there  are  a  disappearance  of  the  bacilli, 
a  fibrosis  of  the  cellular  elements,  and  conversion  of  the  tuberculous 
mass  into  cicatricial  tissue.  The  origin  and  significance  of  the  giant 
cells  have  been  matters  of  much  dispute.  They  have  been  traced  by 
different  observers  to  epithelial  cells,  to  endothelial  cells,  to  connective- 
tissue  cells,  and  to  leukocytes  ;  while  others  have  denied  their  cellular 
character  and  regarded  them  as  lymph-spaces  filled  with  coagulum, 
with  the  swollen  endothelium  of  their  walls  posing  as  nuclei.  The 
view  of  Baumgarten  is  generally  held,  that  the  giant  cells  result  from 
the  overgrowth  of  the  cell  with  multiplication  of  its  nuclei  without  a 
corresponding  division  of  its  substance — possibly  the  result  of  the  irri- 
tation of  the  bacilli  in  its  interior.  The  fusion  of  several  epithelioid 
cells  has  been  invoked  to  explain  the  giant  cell.  Welcker,  repeating 
the  experiments  of  Metschnikoff,  found  "  no  evidence  of  multiple  karyo- 
kinesis  in  the  epithelioid  cells,  and  questions  this  mode  of  formation 


244 


INTERNATIONAL    TEXT- BOOK  OE  SURGERY. 


for  giant  cells.  He  regards  direct  nuclear  division  as  the  most  fre- 
quent mode  of  formation,  but  does  not  exclude  fusion  "  (Hektoen).  So 
far  as  the  significance  of  the  giant  cell  is  concerned,  Baumgarten  and 
Weigert  regarded  it  as  a  stage  in  the  process  of  destruction,  necrobiotic 
in  its  very  conception  ;  while  the  school  of  Metschnikoff,  of  which 
Ludvig  Hektoen  is  the  latest  exponent,  have  marshalled  a  great  deal 
of  evidence  to  prove  that  it  is  a  "  living,  active,  and  defensive  (meso- 
dermal) element,"  the  function  of  which  is  to  counteract  and  destroy 
bacilli,  and  ultimately  to  play  an  important  part  in  the  development  of 
the  victorious  cicatricial  tissue.  The  giant  cell  is  not  an  essential  or 
invariable  accompaniment  of  tubercle.  In  the  process  of  caseation  it 
is  one  of  the  last  structures  to  disappear. 


Fig.  55. — From  tuberculous  testis.  Reticular  tubercle  from  periphery  of  a  nodule.  Shows 
reticulation  radiating  from  the  giant  cell ;  also  fibrils  passing  into  the  cell ;  epithelioid  cells, 
lymphoid  cells  (nuclei  black),  and  the  caseous  patch  surrounded  by  a  fibrous  sheath. 

The  epithelioid  cells  of  tubercle,  the  platycytes  of  Klebs,  are 
intermediate  in  size,  and  mostly  in  position  between  the  giant  cells  and 
the  leukocytes,  and  are  two  or  three  times  the  size  of  the  white  blood- 
cell.  They  are  finely  granular,  somewhat  flattened  cells,  with  a  large 
oval  or  elongated  nucleus,  bearing  some  resemblance  to  an  endothelial 
cell  and  to  certain  epithelial  cells,  which  circumstance  led  Rindfleisch 
to  designate  them  "  epithelioid."  They  commonly  have  only  one 
faintly  stained  nucleus,  but  two  or  more  may  be  present.  They  con- 
stitute the  bulk  of  all  recent  tuberculous  nodules,  or  tracts  of  tuber- 
culous infiltration,  and  being  invariably  present,  and  usually  holding 
certain  definite  relations  to  the  tubercle  bacilli,  may  be  properly 
regarded  as  the  essential  histological  element  of  tubercle. 

Cheyne  asserts  that  the  quickest  way  to  find  tubercle  in  any  given  tissue  is  to  search 
with  a  low  power  for  tracts  of  epithelioid  cells,  and  to  look  amongst  these  for  the  bacilli, 
which  are  easily  to  be  found  in  or  among  them — in  his  opinion,  commonly  within  them — 
while  the  inflammatory  cells  beyond  are  void  of  organisms.  As  in  the  giant  cells,  the 
bacilli,  when  present,  affect  the  neighborhood  of  the  nucleus  of  the  epithelioid  cells.  In 
further  support  of  the  view  that  the  epithelioid  cell  is  the  essential  element  of  tubercle, 
Baumgarten  has  found  in  tuberculous  tissue  nuclear  division  only  in  the  epithelioid  cells. 


SURGICAL    TUBERCULOSIS.  245 

The  sources  of  these  cells  are  various,  and  they  may  be  derived  from  the  epithelium,  from 
the  endothelium  of  blood-  and  lymph-channels,  and  from  the  tissue  and  plasma-cells  of  the 
invaded  structures. 

Caseation  often  affects  the  epithelioid  cells,  but  it  does  not  usually 
begin  in  them,  commencing  more  often  in  the  intercellular  substance 
of  the  giant  cell.  In  the  process  of  healing  they  atrophy  and  are  con- 
verted into  fibrous  tissue. 

The  leukocytes,  or  lymphoid  corpuscles,  are  the  remaining  element 
of  the  tuberculous  nodule  to  be  considered,  and  their  presence  is  a 
convincing  proof  of  the  inflammatory  character  of  the  process.  They 
are  invariably  present,  and  abundant  in  proportion  to  the  acuteness  of 
the  process,  are  scattered  among  the  other  cellular  elements,  and  con- 
gregate at  the  periphery  of  the  nodule.  Bacilli  are  not  found  among 
them,  except  in  sputum  (J.  J.  Mackenzie),  and  they  undergo  no  trans- 
formation except  degeneration.  They  constitute,  however,  a  cellular 
barrier  around  the  tubercle,  and  are  occasionally  reinforced  by  a  fibrous 
wall,  particularly,  as  has  been  said,  if  the  process  has  occurred  within 
a  vessel.  Cohnheim  and  Ziegler  maintain  that  the  leukocytes  form  the 
bulk  of  the  tubercle  nodule ;  the  epithelioid  and  giant  cells  a  minor 
part. 

It  will  thus  be  seen  that  the  tubercle  is  simply  a  circumscribed, 
inflammatory  nodule,  produced  from  proliferation  of  fixed  tissue-cells, 
stimulated  by  the  presence  of  the  Bacillus  tuberculosis  and  its  toxins, 
and  surrounded  by  the  usual  inflammatory  exudate  of  leukocytes. 
Owing,  however,  to  its  infective  character,  it  tends  to  spread  by  con- 
stant multiplication  of  its  foci ;  and  thus  not  only  is  it  locally  infective, 
but  its  virus  may  be  disseminated  from  every  focus  to  distant  parts  by 
the  lymph-  and  blood-currents.  It  may  also  be  conveyed  from  man  to 
animal,  from  animals  to  man  (?),  and  from  man  to  man.  This  tendency 
to  the  formation  of  fresh  tubercles  is  one  of  the  chief  and  distinctive 
characteristics  of  tuberculosis  ;  and  each  tubercle  (nodulation  or  infiltra- 
tion) is  in  its  time  destined  to  retrogressive  change. 

Three  chief  forms  of  degeneration  are  described  :  (a)  Simple  atrophy 
and  disappearance  of  the  tubercle;  (ft)  rapid  caseation  and  breaking 
down,  often  leading  to  what  is  termed  suppuration  (chemical  and  cold) ; 
and  (y)  slower  degenerative  changes,  generally  ending  in  some  degree 
of  calcification,  the  deposit  of  lime  salts  following  upon  the  process  of 
caseation. 

Channels  by  which  the  Virus  Enters  the  System. — That  the 
Bacillus  tuberculosis  may  pass  from  the  mother  to  the  fetus  in  utero 
has  been  indisputably  established,  by  direct  observation  in  both  animals 
and  man  more  than  once,  since  Baumgarten  asserted  its  possibility  ; 
but  that  it  does  so  with  infinite  rarity  the  accumulated  evidence  also 
establishes.  This  mode  of  propagation  may  therefore  be  practically 
disregarded.  What  is  undoubtedly  acquired  by  heredity,  however,  is  a 
peculiar  susceptibility  of  the  tissues  of  the  body  (fluid  and  solid)  to  the 
tuberculous  irritant,  a  condition  which  affords  a  favorable  nidus  for  the 
development  of  the  germ.  The  route  by  which  the  tubercle-germ 
enters  the  system  most  frequently  is,  probably,  the  respiratory  passage, 
and,  next  in  frequency,  with  a  common  avenue  of  approach,  is  the 
digestive  tract.     In  the  former  case,  dust  infected  with  dried  sputum  is 


246  INTERNATIONAL    TEXT- BOOK  OE  SURGERY. 

the  likely  vehicle  of  the  contagium ;  and  in  the  latter,  tuberculized 
articles  of  food,  such  as  meat,  milk,  and  water ;  and  the  mucous  mem- 
brane of  the  nose  may  be  infected  by  a  soiled  handkerchief  or  towel. 
Catarrhal  and  other  subacute  inflammatory  states  of  these  passages  facil- 
itate the  ingress  of  the  germ.  Abrasions  and  inflammatory  lesions  of 
the  skin  afford  an  avenue  of  access  through  this  protective  integument; 
and  the  mucous  membranes  of  the  genito-urinary  and  alimentary  tracts 
may  be  infected  by  accidental  contact  with  germ-laden  substances,  or 
secretions,  or  by  unsterilized  instruments  in  the  hands  of  the  surgeon, 
accoucheur,  or  dentist.  Piercing  the  ears,  tattooing  of  the  skin,  wounds 
of  the  fingers  by  contagium-bearing  china,  the  rite  of  circumcision,  and 
various  minor  lesions  of  the  integument  have  all  afforded  examples  of 
infection  thus  conveyed  ;  and  Laennec  himself  succumbed  to  phthisis 
in  later  years,  induced  by  an  accidental  wound  of  the  finger  incurred  in 
the  examination  of  a  body  dead  of  spinal  tuberculosis. 

The  general  treatment  of  tuberculosis  must  be  based  upon 
common  sense  and  what  we  know  of  the  life  history  of  the  germ  and 
nature's  mode  of  dealing  with  it.  Since  it  is  impossible  always  to  con- 
trol the  dissemination  of  the  seed,  much  attention  must  be  directed  to 
rendering  the  soil  unsuitable  for  its  fructification.  This,  it  is  hardly 
necessary  to  say,  can  be  best  effected  by  general  and  personal  hygiene, 
and  living  as  nearly  continuously  as  possible  in  the  open  air,  without 
incurring  exposure  to  too  extreme  or  sudden  vicissitudes  of  tempera- 
ture. In  this  respect  the  oblivious  third  of  life  spent  in  sleep  demands 
at  least  equal  care  and  supervision  with  the  waking  hours  ;  and  the 
securing  of  an  uninterrupted  and  unlimited  supply  of  pure,  fresh  air, 
unattended  with  draughts,  throughout  the  night,  should  be  for  and  on 
behalf  of  the  tuberculous  patient  the  object  of  earnest  and  constant 
solicitude.  The  maximum  amount  of  sunlight,  the  virtue  of  which, 
locally  applied,  should  not  be  forgotten,  should  be  sedulously  sought. 
To  complete  the  "  trinity  of  healing  graces,"  an  abundant  supply  of 
wholesome,  assimilable  food  may  well  be  added. 

Dryness  and  porosity  of  the  soil,  remoteness  from  the  bed  of 
streams  and  luxurious  vegetation,  propinquity  to  the  sea  or  the  moun- 
tain top,  are  conditions  of  environment  much  to  be  desired. 

Amongst  drugs  which,  under  varying  conditions,  prove  of  service 
may  be  mentioned  iron,  manganese,  quinin  and  strychnin,  iodin,  chlorin, 
and  phosphorus,  with  their  potash,  soda  and  lime  salts,  creosote  and 
guaiacol,  cod-liver  oil  and  ichthyol,  protonuclein  and  methylene  blue, 
and  the  whole  host  of  antiseptics  ;  but  any  or  all  of  these,  in  the  absence 
of  the  first-named  trinity — free  air,  free  sunshine,  free  nutrition — are 
broken  reeds  indeed. 

Surgically,  all  causes  of  local  irritation  and  disease — carious  teeth, 
chronically  enlarged  tonsils,  cutaneous  eruptions,  parasites,  catarrhs, 
ulcerations,  and  what  not — should  be  carefully  sought  for  and  speedily 
removed,  as  giving  rise  to  conditions  markedly  favoring  the  localization 
and  the  fructification  of  the  germs  ;  while,  on  the  other  hand,  local 
fixity  and  rest  (wherever  the  affected  part  may  be),  unimpeded  cir- 
culation, asepticity,  and  whatever  other  conditions  may  be  favorable 
to  cicatrization  must  be  promptly  enforced  as  powerfully  tending  to 
assist  the  tissues  in  combating  the  invaders  of  their  peace  and  sanctity. 


TUBERCULOSIS   OF  SKIN  AND   MUCOUS  MEMBRANE.  247 

Furthermore,  bearing  in  mind  that  the  natural  mode  of  cure  is  by 
fibrosis  when  possible  and  by  ulceration  when  necessary,  it  is  clear  that 
so  soon  as  it  becomes  apparent  that  natural  efforts  at  cicatrization,  fa- 
vored by  such  means  of  art  as  tend  to  sclerogenesis,  are  likely  to  prove 
unequal  to  the  task,  eradication  of  the  local  lesion  at  the  surgeon's 
hands  is  urgently  demanded.  This  may  be  effected  by  fire  and  sword. 
When  possible,  complete  ablation  with  full  antiseptic  care  and  primary 
union  is  much  to  be  preferred.  But  where  the  local  conditions  render 
this  impossible  or  inadmissible,  free  excision,  with  removal  of  under- 
mined and  infected  skin,  and  thorough  scraping  of  the  affected  focus, 
may  be  hopefully  resorted  to.  This  should  be  followed  by  swabbing 
with  chlorid-of-zinc  solution  (40  grains — 2.6  gm. — to  the  ounce),  or 
with  pure  carbolic  acid,  penetrating  all  recesses,  nooks,  and  crannies, 
and  afterward  by  packing  with  sterilized  iodoform  and  iodoform  gauze, 
with  a  large  antiseptic  dressing,  and  fixation  by  splintage,  where  avail- 
able. Under  these  circumstances,  recovery  is  much  slower,  and  may 
be  interrupted  by  recrudescences  and  relapses,  demanding  a  repetition 
of  the  treatment. 


TUBERCULOSIS    OF    SKIN   AND    MUCOUS    MEMBRANE. 

General. — («)  Lupus  ;  (,3)  tuberculosis  vera  cutis  ;  (7)  scrofuloderma. 

Local. — These  are  essentially  localized — that  is,  unassociated  with 
general  tuberculosis  ;  and  Zeisler  describes  four  varieties  :  (a)  Verruca 
necrogenica  (anatomical  tubercle) ;  (J?)  tuberculosis  verrucosa  cutis  ; 
(c)  tuberculosis  papillomatosa  cutis;  (d)  tuberculous  ulcerations  of 
skin,  of  tongue,  of  pharynx  and  larynx,  of  different  parts  of  the  ali- 
mentary tract,  including  fistula  in  ano. 

I/UptlS  Vulgaris. — Senn  makes  the  statement  that  "  all  forms 
of  primary  tuberculosis  of  the  skin  are  the  result  of  direct  inoculation 
with  tubercle  bacilli ";  and  if  we  could  accept  this  dictum  implicitly 
and  without  reserve,  then  we  should  agree  with  what  he  says  about  the 
description  given  of  the  different  forms  of  tuberculosis  of  the  skin — 
viz.:  "It  is  time  that  these  immaterial  and  unimportant  distinctions 
should  be  set  aside,  and  these  different  affections  should  be  included 
under  one  head,  as  primary  tuberculosis  of  the  skin,  since  all  of  them 
present  the  same  histological  structure,  and  all  are  caused  by  direct 
inoculation  with  tubercle  bacilli."  But  "Jonathan  Hutchinson  does 
not  accept  the  inoculation  of  the  tubercle  bacillus  from  without  as  an 
ordinary  cause  of  lupus.  It  seems  to  him  far  from  probable  that  the 
parasite  exists  during  long  periods  in  a  state  of  latency,  from  which 
any  local  injury  may  arouse  it  into  a  state  of  activity."  All,  however, 
are  agreed  upon  the  causative  agency  of  the  Bacillus  tuberculosis. 
This  was  foreshadowed  clinically  for  a  long  time  before  the  demonstra- 
tion was  forthcoming.  Thus  Hebra  and  Fuchs  agreed  with  the  leading 
French  and  English  authors  who  taught  that  lupus  was  one  of  the 
manifestations  of  scrofula,  and  that  anatomically  it  was  composed  of 
granulation-tissue. 

Virchow,  Rindfleisch,  Hueter,  and  many  others  very  nearly  approached  the  truth,  but 
Friedlander  was  the  first  to  assert  positively  its  tuberculous  character  and  to  demonstrate  the 


248  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

presence  of  miliary  tubercle  in  it.      The  crucial  test  of  bacteriological  experiment  has  been 
decisive. 

The  artificial  tuberculosis  produced  in  animals  by  implantation  of  lupoid  tissue  has  been 
found  by  numerous  investigators  to  contain  the  Bacillus  tuberculosis. 

"  The  characteristic  and  primary  feature  of  lupus  is  a  reddish-brown, 
or  pinkish,  or  yellowish  nodule,  becoming  paler  but  not  disappearing 
on  pressure,  of  soft  consistency  when  pressed  upon  by  a  blunt  instru- 
ment, situated  beneath  the  epidermal  layers  of  the  corium  "  (Bowen). 
This  nodule,  or  lupoma,  varies  in  size,  pursues  a  slow  and  chronic 
course,  and  in  its  evolution  or  involution  presents  a  variety  of  appear- 
ances characterizing  the  different  forms  of  lupus. 

Leloir  affirms  that  at  the  seat  of  the  disease  tactile  sensibility  is  diminished  and  the  local 
temperature  raised.  If  the  nodule  is  not  raised  above  the  surface  and  is  hardly  perceptible 
to  the  touch,  it  is  termed  lupus  maculosus.  The  macular  form  may  be  preserved  throughout,  or 
the  nodule  may  grow  into  elevations  perceptible  to  the  touch,  giving  rise  to  what  is  termed 
lupus  elevi.  When  many  such  nodules  have  coalesced  into  a  mass,  the  swelling  has  been 
termed  lupus  tumidus.  If  these  patches  do  not  ulcerate,  a  process  of  involution  and  con- 
traction occurs,  the  nodule  shrinking  up,  and  the  overlying  epidermis  consequently  becomes 
thicker  and  scaly.  Lupus  exfoliativus  is  thus  produced,  tending  to  end  in  a  cicatricial  con- 
traction. 

The  original  lupus  nodule  is  apt  to  be  attended  by  a  circle  of  satel- 
lites, and,  the  central  portions  undergoing  absorption  and  cicatrization, 
while  the  periphery  is  breaking  down  and  spreading  irregularly,  a  very 
common,  important,  and  intractable  clinical  variety  arises,  which  is  of 
long  duration,  highly  deforming,  resistant  to  treatment,  and  called 
lupus  serpiginosus. 

When,  on  the  other  hand,  the  process  of  softening  and  breaking 
down  from  necrobiosis  occurs,  the  variety  termed  lupus  exulcerans  or 
lupus  exedens  is  developed.  The  so-called  ulcers  thus  arising  are  often- 
times covered  with  crusts  composed  of  the  cheesy  material  of  the 
degenerated  tuberculous  tissue,  and  oftentimes  the  products  of  second- 
ary septic  infection,  and  a  condition  arises  sometimes  closely  resembling 
eczema  impetiginosum.  When  the  crusts  are  removed,  the  lupus  ulcer 
is  seen  to  present  soft,  reddish  borders,  and  a  red  or  grayish,  granular 
base,  painless  and  insensitive,  and  of  soft  consistency.  Sometimes  an 
exuberant  granular  growth  occurs  and  large  fungoid  masses  are  devel- 
oped, giving  rise  to  lupus  papillaris  verrucosus,  the  favorite  seat  of 
which  is  the  nose.  Lupus  vorax  and  lupus  phage denique  are  classifica- 
tions descriptive  of  the  extent  and  depth  of  the  ulcer.  Lupus  is 
impartially  destructive  in  its  progress,  and  all  tissues  are  in  turn  de- 
stroyed— cartilage,  particularly,  falling  an  easy  prey. 

Localities. — The  face  is  the  favorite  site  for  all  forms,  the  nose 
especially ;  and  of  this  organ,  particularly  the  alae,  and  sometimes  the 
mucous  membrane,  where  it  oftentimes  exists  as  an  obstinate  crusting. 
The  cartilaginous  septum  is  attacked  with  avidity,  but  the  bone  not  so ; 
whence  results  the  appearance  described  as  the  "  lopped-off "  nose  of 
lupus,  as  distinguished  from  the  "  sunken-in  "  nose  of  syphilis.  The 
cheeks,  lips,  and  ears  are  frequently  attacked,  the  external  auditory 
canal  and  membrana  tympani  occasionally.  Lupus  of  the  forehead 
and  scalp  is  rarely  primary,  though  Hebra,  Kaposi,  and  Leloir  have 
described  one  case  each.  One  writer  has  aptly  said  that  the  disease 
may  spread  anywhere  and  everywhere  until  naught  remains  but  the 


TUBERCULOSIS   OF  SKIN  AXD   MUCOUS  MEMBRANE.  249 

cicatrix  stretched  tightly  over  the  bone,  studded  here  and  there  with 
nodules  of  new  disease. 

Lupus  of  the  extremities  is  not  uncommon,  and  is  met  with  next  in 
frequency  to  the  face.  It  is  most  intense  from  the  elbows  and  hands 
downward,  frequently  serpiginous  in  outline,  and  begins  over  the  points 
of  the  articulations,  rarely  upon  the  palms  or  soles.  Great  deformity 
from  cicatricial  contractions,  fistulas,  caries,  necrosis,  and  elephantiasis 
from  obstructed  circulation,  recurrent  lymphangitis,  and  dermatitis  may 
result.  Lupus  of  the  genitalia  is  very  rare.  Hebra  met  with  it  once 
upon  the  penis,  and  Taylor  has  seen  it  on  the  vulva. 

Lupus  of  mucous  membranes  is,  perhaps,  rare  as  a  primary  affection, 
but  secondarily  it  occurs  very  frequently.  Yet  primary  lupus  of  the 
mucous  membrane  of  the  nose  is  not  infrequent,  and  is  often  mistaken 
for  eczema  narium.  Indeed,  Neisser  believes  that  the  most  frequent 
extension  is  from  the  nose  to  the  face.  The  special  characteristics  are 
not  so  marked  in  the  mucous  membranes,  owing  to  the  thin  epithelial 
covering-  not  offering  much  resistance  to   the   infiltration,  and  to  the 

o  o  ... 

constant  maceration  by  the  secretions.  According  to  Chiari  and  Riehl, 
the  lupus  nodule  of  the  skin  is  replaced  in  the  mucous  membranes  by 
papillary  excrescences,  and  they  assert  that  the  brown-red  impalpable 
nodules  in  the  cicatrix  are  pathognomonic.  Lupus  of  the  conjunctival 
mucous  membrane  is  rare  as  a  primary  affection,  and  attacks  the  lower 
lid  first.  Lupus  of  the  mouth  and  pharynx  generally  coexists  with 
lupus  of  the  skin.  It  appears  upon  the  gums,  and  Leloir  once  found 
it  on  the  vault.  In  the  tongue  it  is  rare.  In  the  larynx  Leloir  met 
with  it  in  2  per  cent,  of  his  cases  ;  and  Chiari  and  Riehl's  statistics 
showed  that  the  epiglottis  was  almost  always  affected  (35  out  of  38 
cases). 

Leloir  has  described  a  lupus  collo'ide  and  myxomateux  in  which  the 
degenerations  characterized  by  these  names  have  occurred. 

Epithelioma  or  epitheliomatous  change  not  infrequently  complicates 
lupus. 

Diagnosis. — The  diagnostic  features  of  lupus  may  be  said  to  be  the 
youth  of  the  patient,  the  "  apple-jelly  "  appearance  of  the  nodules,  the 
cicatrization  of  the  center  while  spreading  at  the  margin,  and  the 
tendency  to  relapse. 

The  Prognosis. — Owing  mainly  to  the  difficulty  of  removing  the 
growth  in  its  favorite  locality — the  foce — beyond  the  area  of  local 
infectivity,  the  ultimate  prognosis  is  always  doubtful.  The  prospect 
of  local  improvement  under  judicious  treatment  is  always  good. 

Treatment. — The  general  treatment  of  lupus  is  that  which  is  proper 
for  all  forms  of  tuberculosis.  In  the  local  treatment  it  would  naturally 
be  expected,  in  view  of  the  character  of  the  affection,  that  excision 
would  prove  the  most  useful  and  satisfactory  remedy.  Practical  expe- 
rience, however,  has  shown  that  this  is  not  the  case,  owing  doubtless  to 
the  before-mentioned  difficulty  of  cutting  wide  of  the  disease  in  those 
portions  of  the  body  where  it  most  commonly  occurs.  For  this  reason 
relapses  in  the  cicatrix  are  not  uncommon  after  excision.  Linear  scar- 
ification has  been  much  lauded  by  Volkmann  in  Germany,  Vidal  in 
France,  and  Balmanno  Squire  in  England.  Curetment  with  a  sharp 
spoon  or  curet,  being  more  generally  applicable  in  all  situations,  has, 


250  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

on  the  whole,  given  the  most  satisfactory  results,  when  freely  followed 
by  the  application  of  the  cautery  or  antiseptics  and  iodoform  dressings. 
Bougard's  paste  (cocainized)  occasionally  finds  useful  application  here, 
and  the  thermocautery,  either  along  with  or  following  curettage,  is  a 
valuable  instrument.  Caustics  of  various  kinds,  but  particularly  the 
pointed  stick  of  silver  nitrate  with  which  the  nodules  may  be  indi- 
vidually penetrated  and  destroyed,  are  oftentimes  attended  with  satis- 
factory destruction  of  the  growth. 

Tuberculosis  vera  cutis  is  a  rare  affection,  always  secondary  to  tuberculosis  of 
mucous  membranes,  and  called  by  the  French  ulcere  des phthisiques.  Chiari  was  the  first  to 
notice  this,  on  the  lower  lip  of  a  cadaver,  and  Jarisch  intra  vitam.  The  location  is  almost 
exclusively  at  the  junction  of  skin  and  mucous  membrane  ;  but  Jarisch,  Leloir,  and  Vallas 
have  reported  instances  elsewhere.  The  characteristic  appearances  are  simple  shallow  ulcers 
with  edges  made  up  of  small  jagged  indentations,  resulting  from  the  degeneration  of  mili- 
ary tubercles,  giving  a  "gnawed-out  "  appearance.  The  floor  is  not,  as  a  rule,  crusted,  but 
is 'covered  with  a  seropurulent  fluid,  and  with  occasional  yellowish  elevations,  representing 
miliary  tubercles,  scattered  over  it.  These  ulcers,  unlike  those  of  lupus,  are  usually  painful, 
probably  owing  to  the  site  of  occurrence.  When  occurring  on  the  glans  penis  they  have  been 
shown  to  be  secondary  to  tuberculosis  of  the  urinary  passages,  except  when  inoculated  by 
the  Jewish  rite  of  circumcision,  of  which  Lehmann  has  recorded  io  cases.  Similarly  in 
the  vulva  they  are  secondary  to  tuberculosis  of  the  uterus  and  tubes.  The  course  of  these 
ulcers  is  variable,  depending'  largely  upon  the  progress  of  the  general  affections  with  which 
they  are  associated. 

Scrofuloderma  is  that  form  of  tuberculosis  which  affects  the  sub- 
cutaneous connective  tissue.  It  may  be  either  primary,  or  consecutive 
to  softening  of  lymph-glands,  or  occur  as  perilymphangitic  nodules. 

Verruca  necrogenica  (anatomical  tubercle)  is  found  upon  the  fingers 
and  the  dorsal  surfaces  of  the  hands  of  pathologists,  the  result  of 
infection.  It  begins  as  a  simple  red  nodule,  which  becomes  pustular 
and  soon  covered  with  a  scab.  Gradually  it  spreads  on  the  surface, 
becomes  thicker,  and  is  covered  with  papillary  growths,  giving  a  warty 
appearance.  It  has  a  well-defined  margin.  Here  and  there  on  the 
surface  are  seen  small  points  of  pus,  which  can  be  squeezed  out  from 
the  deeper  layers.  In  some  cases  the  eruption  is  painful,  in  others  indo- 
lent ;  in  all,  it  may  spread  through  the  lymphatics  and  give  rise  to  fatal 
visceral  tuberculosis  (Warren). 

Tuberculosis  verrucosa  cutis  was  first  described  in  1886  by  Riehl 
and  Paltauf.  In  this  the  patches  vary  from  the  size  of  a  dime  to  that 
of  a  silver  dollar.  When  fully  developed,  three  concentric  zones  may 
be  observed,  the  peripheral  one  erythematous,  the  second  composed  of 
little  pustules  or  of  scales  covering  pustules,  the  skin  of  a  reddish- 
brown  color  and  infiltrated,  and  the  central  zone  raised  0.1  inch  (2-3  mm.) 
and  covered  with  papillary  growths  at  the  center.  Between  the  warty 
growths  are  fissures  and  small  abscesses.  The  growth  is  very  sensitive, 
of  slow  progress,  lasting  from  two  to  fifteen  years.  The  lesion  is  situ- 
ated in  the  superficial  layers  of  the  cutis,  rarely  descending  to  the  level 
of  the  sudoriparous  glands  (Warren). 

Tuberculosis  Papillomatosa  Cutis. — Of  this  an  isolated  case  has  been  described 
by  Morrow.  It  was  remarkable  for  the  extent  and  amount  of  the  warty  tubercular  growth, 
which  involved  the  cheeks,  the  upper  lip,  the  nose,  and  the  eyelids.  The  hypertrophic 
condition  and  the  papillary  excrescences  were  noteworthy  features  ;  but  it  is  doubtful  if  it 
deserve  a  separate  classification. 

Tuberculous  Nodes;  Scrofulous  Nodes;  Scrofulous  Qummata. — 

Under  this  head  has  been  described  a  subcutaneous  manifestation  of 


TUBERCULOUS  LYMPHADENITIS.  25  I 

tuberculosis,  at  first  hard  and  nodular,  afterward  softening,  spreading, 
and  breaking  down.  Its  seat  is  commonly  the  subcutaneous  con- 
nective tissue,  but  it  sometimes  starts  from  the  periosteum,  and  on 
ulceration  exposes  bare  bone.  When  occurring  over  the  skull  and 
the  patella,  perforation  of  the  bone  cannot  infrequently  be  made  out. 
The  treatment  consists  in  excision  where  admissible ;  and  where  this 
cannot  be  done,  thorough  and  vigorous  scraping  followed  by  the 
cautery,  chlorid  of  zinc  (40  grains — 2.6  gm. — to  the  ounce),  pure  car- 
bolic acid,  and  iodoform. 

Lupus  erythematosus  has  been  included  amongst  the  skin-manifestations  of  tuber- 
culosis by  some  advanced  authorities  under  the  leadership  of  Besnier  ;  but  the  tuberculous 
origin  of  this  symmetrical,  later-appearing  affection  has  never  yet  been  satisfactorily  estab- 
lished, and  most  dermatologists  strenuously  deny  it  on  both  clinical  and  pathological 
grounds. 

Treatment  of  Skin  Tuberculosis. — Dry  hot  air  (driven  through  a 
red-hot  metal  tube,  after  Hollander's  method,  raising  it  to  a  tempera- 
ture of  3000  C),  directed  upon  the  affected  area,  exercises  a  remarkable 
and  beneficial  caustic  influence  upon  the  part.  The  Rontgen  rays,  con- 
centrated sunlight,  and  the  electric  light  have  been  spoken  of  favorably, 
as  has  also  electrolysis.  In  the  way  of  general  treatment,  arsenic  is 
the  drug  of  greatest  service,  combined  with  various  tonics.  The 
cantharidate  of  soda  or  potash  has  been  recommended  for  interstitial 
use  (Liebreich).  Koch's  Tuberculin  R,  administered  within  a  reaction- 
ary limit  of  ^°  C,  has  certainly  proved  of  great  temporary  utility. 

Tuberculous  ulcerations  of  local  origin,  as  in  wounds  by  broken 
spittoons,  infection  of  wounds  by  sputum-soiled  articles,  the  saliva  of 
the  operator  in  the  Jewish  rite  of  circumcision,  and  so  forth,  are  best 
treated  by  excision  when  applicable ;  but,  when  from  extent  or  locality 
this  is  out  of  the  question,  compresses  soaked  in  mercuric  chlorid  solu- 
tion, 1-2  grains  (0.065-0. 13  gm.)  to  the  ounce  (White),  or  perman- 
ganate of  potash,  ^  per  cent,  to  2  per  cent.  (Butte),  may  be  employed, 
the  pain  being  relieved  by  the  subsequent  application  of  a  cocain  oint- 
ment. Salicylic  acid  in  ointment,  or  in  Unna's  plaster-mulls,  or  made 
into  a  paste  with  creosote  and  balsam  of  Pern  (cinnamic  acid)  finds  a 
useful  application  in  tuberculosis  of  the  skin. 

Old  sinuses,  as  in  Pott's  disease,  may  be  dissected  or  thoroughly 
scraped  out,  swabbed  with  a  95  per  cent,  glycerin  solution  of  carbolic 
acid,  sutured,  and  compressed.    Not  infrequently  primary  union  occurs. 

TUBERCULOUS    LYMPHADENITIS. 

This  is  one  of  the  most  common  manifestations  of  the  tuberculous 
process,  and  constitutes  a  large  proportion  of  the  cases  of  chronic 
lymphadenitis  that  come  under  observation.  The  glands  most  likely 
to  be  affected  are,  of  the  superficial  set,  the  cervical  glands,  the  cubital, 
and  less  frequently  the  axillary  (Volkmann).  The  glands  of  the  lower 
extremity  are  much  less  often  affected.  As  a  post-mortem  observation 
it  has  been  stated  that  in  children  the  order  of  frequency  is  the  cervical, 
the  mediastinal,  the  mesenteric,  and  the  retroperitoneal ;  and  it  is  an 
astonishing  fact  that  in  more  than  one-half  of  all  the  autopsies  made 
upon   children,   evidences   of   tuberculous    adenitis    are   to    be    found. 


252  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

While  the  frequency  of  incidence  is  as  above  stated,  any  or  all  of  the 
glands  of  the  body  may  be  implicated. 

The  affection  may  be  primary  or  secondary.  When  secondary 
it  is  generally  engrafted  upon  catarrhal  affections  of  the  mucous  or 
cutaneous  surfaces,  tonsils,  carious  teeth,  cutaneous  irritations ;  and 
Treves  has  attributed  the  great  frequency  of  the  implication  of  the 
cervical  glands  to  the  extensive  collections  of  adenoid  tissue  found  in 
the  adjoining  mucous  membranes.  The  bacilli  are  generally  picked  up 
on  the  mucous  or  cutaneous  surfaces,  and  so  come  by  the  lymph-cur- 
rent to  the  glands,  but  they  may  gain  access  by  the  blood-stream.  The 
affection  is  a  common  one  in  childhood  and  early  adult  life,  but  may 
be  met  with  between  seventy  and  eighty  years  of  age  as  "  senile 
scrofula." 

The  symptoms  are  a  slow,  gradual,  painless  enlargement  of  the 
glands,  often  coming  on  insidiously,  of  variable  duration,  and  frequently 
proceeding  by  fits  and  starts.  The  glandular  swellings  are  at  first  dis- 
crete and  movable,  then  become  confluent,  and  when  peri-adenitis  has 
occurred  subsequently  adherent.  When  adhesions  have  been  formed, 
softening  may  quickly  follow  and  ulceration  be  developed.  Suppuration 
or  liquefaction  takes  place  slowly.  It  may  become  stationary  or  even 
retrogressive,  cheesy  or  calcareous.  The  skin  becomes  thin,  under- 
mined, reddish-purple  or  blue,  and  gradually  gives  way,  discharging 
cheesy  or  curdy  pus  and  debris ;  this  condition  may  continue  for 
months  or  even  years.  The  discharging  surface  may  be  contracted 
down  to  the  dimensions  of  a  sinus,  leading  to  a  caseous  or  cretaceous 
focus.  It  may  heal  over  and  practically  cease  from  time  to  time,  or  it 
may  ulcerate  widely  and  present  a  reddish-gray,  fungating,  and  fleshy 
protruding  mass.  When  healing  occurs,  the  cicatrices  are  apt  to  be 
thin,  blue  and  weak,  adherent,  and  traversed  by  hypertrophic  bands, 
forming  irregular,  puckered,  and  hypertrophic  scars.  Occasionally, 
however,  the  scars  are  of  surprising  fineness  and  suppleness. 

So  far  as  the  pathological  anatomy  is  concerned,  we  find  the 
ordinary  phenomena  of  a  simple  inflammation  plus  tuberculous  foci 
(gray  or  yellow),  followed  by  caseation,  liquefaction,  or  cretification. 
Bacilli  are  absent  in  the  later  stages,  but  the  tissues  are  still  infective, 
probably  owing  to  the  presence  of  spores. 

The  diagnosis  must  be  made  from  simple  adenitis,  from  lymph- 
adenoma  and  lymphosarcoma. 

The  treatment  resolves  itself  into  general  and  local.  The  general 
is  that  which  is  appropriate  for  other  tuberculous  affections.  The  local 
involves  the  treatment  of  the  gland,  the  sinuses,  and  the  abscesses. 
While  the  glands  are  still  small  and  few  in  number,  surgical  interven- 
tion may  not  be  required.  Painting  the  surface  with  iodoform,  ichthyol, 
and  belladonna,  and  securing  fixity  for  the  part,  together  with  the  con- 
stitutional treatment,  may  be  all  that  is  required.  If,  however,  they 
manifest  a  tendency  to  enlarge,  to  run  together,  and  to  soften,  they 
should  be  promptly  removed.  In  their  removal  the  attempt  should 
always  be  made  to  extirpate  the  gland  with  its  containing  capsule, 
and  in  view  of  the  importance  of  the  structures  to  which  they  are  not 
infrequently  adherent,  after  the  gland  is  reached,  blunt  dissection  is  for 
the  most  part  appropriate.    If  the  capsule  be  accidentally  or  of  necessity 


TUBERCUL  O US   L  } 'MPHADENITIS.  253 

opened,  the  contents  should  be  removed,  and  the  walls  quickly  scraped 
with  a  sharp  curet,  the  cavity  swabbed  out  with  chlorid  of  zinc  (40 
grains — 2.6  gm. — to  the  ounce)  or  a  95  per  cent,  solution  of  carbolic 
acid  in  glycerin,  and  subsequently  packed  with  iodoform  gauze  for 
three  or  four  days.  At  the  end  of  this  time  the  gauze  should  be 
removed  and  the  opposite  surfaces  brought  together  and  compressed, 
under  which  circumstances  primary  union  will  not  infrequently  occur 
if  uniform  pressure  and  absolute  immobility  be  maintained. 

The  sinuses,  when  suitably  located,  are  also  best  dealt  with  by  com- 
plete excision,  as  will  not  infrequently  happen  in  cases  of  fistula  in  ano. 
If  they  cannot  be  excised,  however,  they  should  be  thoroughly  curetted, 
and  when  occurring  in  the  subcutaneous  tissue  the  little  bunch  of  exu- 
berant granulations,  which  marks  the  entrance  to  the  subjacent  tuber- 
culous glandular  focus,  should  always  be  sought  for  and  diligently 
followed  up.  After  a  free  use  of  the  sharp  curet,  the  sinuses  should 
be  treated  precisely  as  before  mentioned  with  regard  to  the  glands 
whose  capsule  has  been  opened. 

The  treatment  of  the  abscesses  is  conducted  upon  the  same  prin- 
ciple, and  often  although  very  extensive,  as  in  cases  of  Pott's  disease 
of  the  spine,  or  the  so-called  psoas  abscess,  several  well-placed  inci- 
sions will  give  access  to  the  whole  cavity,  allowing  of  a  thorough 
curetment  of  the  granulation-tissue,  subsequent  disinfection,  and  dress- 
ing, as  in  the  case  of  the  sinuses.  Occasionally  cases  will  be  met  with 
in  which  the  iodoform  packing  may  be  omitted  and  primary  union 
sought  at  once  by  judicious  compression  and  fixation. 

For  inducing  sclerogenesis  about  tuberculous  foci  Lannelongue 
highly  recommended  the  injection  of  weak  solutions  of  chlorid  of 
zinc  into  and  around  the  focus.  Liebreich  has  highly  lauded  the  vir- 
tues of  the  cantharidate  of  soda  and  potash  as  being  capable  of  stim- 
ulating the  vital  resistance  of  the  tissues. 

Tuberculosis  mammae  is  a  rare  disease,  and  the  literature  of  the 
subject  is  very  scant.  Roux  made  a  collection  of  34  cases,  of  which  2 
were  males.  In  2  cases  both  breasts  were  affected  ;  the  age  varied  from 
sixteen  to  fifty-two  years ;  and  in  24  of  the  cases  the  tuberculosis  of 
the  breast  was  secondary  to  its  occurrence  elsewhere.  As  showing  the 
functioning  of  the  breast  as  the  predisposing  cause,  Mandry's  collection 
of  40  cases  gave  only  1  in  the  male  breast ;  most  were  developed  shortly 
after  confinement,  the  ages  varying  from  seventeen  to  fifty-two  years. 

We  owe  the  first  scientific  study  of  the  subject  to  Dubar,  who  published  his  work  in  1881, 
and  who  was  followed  by  Le  Dentu  and  by  Olnacker  in  1883.  Roswell  Park  of  Buffalo 
was  the  first  to  treat  of  the  subject  in  English,  in  1887.  Since  then  Orthmann,  Hering, 
Mandry,  Roux,  Campenon,  Lane,  Shattuck,  and  others  have  made  contributions  on  the 
subject.     A  general  summary  was  published  by  Powers  in  the  Annals  of  Surgery  in  1894. 

During  lactation  it  is  a  double  source  of  danger,  being  liable  to 
infect  the  mother  and  the  child  with  miliary  tuberculosis. 

It  usually  commences  around  an  acinus  of  the  gland  or  even  within 
one.  The  disease  begins  insidiously.  One  or  more  swellings  of  irreg- 
ular shape  appear,  increase  pretty  rapidly,  tend  to  soften  and  break 
down  in  the  center,  and  form  a  chronic  abscess,  which,  if  left  alone, 
eventuates  in  fistulae  or  sinuses  which  have  no  tendency  to  heal,  and 
will  present  the  usual  undermined  appearance  of  a  tuberculous  sinus. 


254  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

As  before  mentioned,  the  periods  of  functional  activity  are  most 
prone  to  the  affection,  it  occurring  during  puberty,  pregnancy,  and  the 
puerperium. 

Cold  abscesses  and  chronic  fistulae  are  the  forms  generally  assumed 
by  tuberculosis  of  the  breast  and  axilla  when  they  come  under  notice. 
Three  forms  have  been  described:  (a)  The  single  diffuse  swelling; 
(,3)  multiple  fluctuant  areas ;  and  (y)  one  or  more  hard  nodules  in 
different  stages  of  caseation. 

Axillary  glands  may  be  involved  with  or  without  the  formation  of 
abscess,  or  they  may  be  entirely  unaffected.  Disseminated  tubercles 
may  be  found  in  the  tissues  around  the  breast.  The  disease  tends  to 
spread  by  the  lymph-paths. 

The  diagnosis  is  best  made  by  bacteriological  examination,  other- 
wise it  may  remain  uncertain,  even  when  associated  with  tubercle  else- 
where. The  upper  and  outer  quadrant  of  the  gland  is  that  usually 
attacked ;  and  the  onset  is  sometimes  secondary  to  tuberculosis  of  the 
axillary  glands. 

Symptoms  of  cold  submammary  abscess  may  be  met  with  secondary 
to  tuberculosis  of  the  ribs,  sternum,  or  pleura,  or  to  empyema.  In 
primary  tuberculosis  of  the  mamma,  infection  may  have  taken  place 
along  the  milk-ducts  or  by  way  of  an  open  wound  in  the  breast  or 
nipple. 

Spontaneous  healing  has  been  observed  where  the  foci  were  small 
and  few.  Encapsulation  and  calcification  may  exceptionally  occur; 
but  the  general  tendency  is  to  persist  indefinitely  and  to  spread — a 
constant  drain  upon  the  vital  powers  and  a  continual  menace  to  the 
general  health. 

The  treatment  is  the  same  as  for  carcinoma,  by  early  and  complete 
ablation,  together  with  the  lymph-glands,  if  any  be  found  to  be  involved. 
If  the  patient  be  unwilling  to  sacrifice  the  breast,  the  treatment  already 
laid  down  for  sinuses  and  abscesses  will  be  appropriate  and  sometimes 
successful. 

TUBERCULOSIS  OF  THE  SEROUS  MEMBRANES. 

Serous  membranes  may  be  affected  by  tuberculosis  either  primarily 
or  secondarily.  In  the  latter  case  the  focus  may  be  found  in  a  subja- 
cent viscus,  in  neighboring  connective  tissue,  or  in  adjacent  lymph-gland 
or  bone.  Thus  we  may  have  tuberculous  meningitis  from  middle-ear 
or  mastoid  disease,  pleuritis  from  pulmonary  or  rib  tuberculosis,  and 
peritonitis  from  tuberculosis  of  the  mesenteric  glands,  intestines,  or 
Fallopian  tubes. 

The  role  of  the  surgeon  in  these  cases  is  generally  that  of  an  oper- 
ator, and  the  diagnosis,  causation,  and  associations  or  complications  are 
commonly  determined  before  he  is  called  in.  His  part  is  therefore 
limited  to  the  local  operative  treatment. 

Tuberculous  Meningitis. — The  evidence  so  far  accumulated 
does  not  warrant  a  belief  that  any  material  amelioration  is  to  be  ex- 
pected from  surgical  intervention  in  this  condition.  It  goes  to  show, 
however,  that  it  may  contribute  somewhat  to  euthanasia  by  diminution 
or  arrest  of  convulsions  through  the  removal  of  tension  by  puncture 
or  aspiration  of  intracranial  or  spinal  fluid.     The  withdrawal  and  ex- 


TUBERCULOSIS   OF   THE   SEROUS   ME  MB  RAXES.  255 

amination  of  fluid  has,  however,  on  numerous  occasions  proved  helpful 
in  diagnosis.  Thus  D'Astros  is  of  opinion  that  "  in  ventricular  hydro- 
cephalus the  small  proportion  of  albumin  and  the  abundance  of  sodium 
chlorid  found  in  the  exudate  furnish  a  ready  means  of  distinguishing 
the  cerebrospinal  fluid  from  that  found  in  the  extraventricular  effusion." 
Whilst  he  expects  nothing  from  surgical  procedure  in  the  former,  he 
hopes  to  find  much  practical  utility  in  the  latter. 

The  older  methods  of  relieving  intracranial  tension  by  the  use  of 
the  trephine  and  puncture  have  in  a  measure  been  superseded  by  the 
adoption  of  the  suggestion  made  by  YVynter,  and  carried  out  by 
Quincke,  of  withdrawing  the  fluid  by  puncture  in  the  second,  third,  or 
fourth  intervertebral  space  of  the  lumbar  spine.  Furbringer  has  had 
quite  an  extensive  experience  with  the  method,  and  in  37  cases  of 
tuberculous  meningitis,  he  succeeded  in  demonstrating  the  tubercle 
bacillus  in   30,  or  80  per  cent. 

The  puncture  should  be  made,  with  the  patient  sitting  up  or  bent 
forward,  on  the  plane  of  the  junction  of  the  superior  and  middle  thirds 
of  the  spinous  process,  about  two  fingers'  breadth  from  the  median 
line.  After  passing  through  the  skin  the  needle  should  be  directed  a 
little  upward  and  inward.  "  With  new-born  infants  the  needle  should 
penetrate  1  cm.  (|  inch),  and  with  older  children  the  depth  should  be 
increased,  approaching  7  cm.  (2f-  inches),  which  is  the  depth  necessary 
in  the  robust  adult."  Heubner  prefers  lumbar  puncture  to  tapping  of 
the  ventricles  in  chronic  hydrocephalus.  The  method,  however,  has 
not  been  uniformly  void  of  unpleasant  symptoms.  It  goes  without 
saying  that  the  strictest  antiseptic  precautions  must  be  rigidly  observed 
in  its  practice. 

In  tuberculous  pleurisy  and  empyema,  on  the  other  hand, 
surgery  finds  a  field  for  frequent  useful  and  beneficent  employment, 
as  well  as  in  the  non-tuberculous  varieties,  though  it  is  with  the  former 
alone  that  the  present  chapter  is  concerned.  According  to  Netter's 
tables,  empyema  in  children  is  of  tuberculous  origin  in  only  25  per 
cent,  of  the  cases,  the  other  75  per  cent,  being  due  to  the  Bacillus 
pneumoniae  (53.6  per  cent,  to  60  per  cent.),  the  Staphylococcus  pyog- 
enes, or  Streptococcus,  Eberth's  bacillus,  and  the  Bacillus  coli  com- 
munis ;  while  the  statistics  of  Netter  and  of  Eichhorst  placed  the  fre- 
quency of  tuberculous  pleurisies  at  65.2  to  68.5  per  cent,  in  adults. 

Three  methods  of  treatment  are  available — simple  aspiration,  drain- 
age, and  rib-resection  (thoracoplasty,  or  Estlander's  operation).  In  every 
case  operation  should  be  preceded  by  the  withdrawal  of  fluid  by  the 
hypodermic  syringe  or  special  exploring  trocar  for  verification  of  the 
diagnosis,  care  being  taken  that,  after  disinfection  of  the  syringe  and 
needle,  any  coagulating  antiseptic  shall  be  removed  in  sterilized  water 
before  the  puncture  is  made. 

Simple  Aspiration  (Thoracentesis,  Paracentesis  thoracis). — The 
sites  of  election  for  the  puncture  are  the  sixth  or  seventh  space,  just 
in  front  of  the  posterior  fold  of  the  axilla ;  the  eighth  or  ninth  space, 
external  to  the  angle  of  the  scapula  ;  and  the  fifth  space,  just  external 
to  the  costal  cartilage  (as  recommended  by  John  Marshall),  or  where 
bulging  is  most  prominent  or  dulness  greatest. 

The  means  employed  are  the  ether  spray  or  ethyl  chlorid  or  Schleich's 


256  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

solution  as  a  local  anesthetic,  cocain  being  generally  inadvisable  on  ac- 
count of  its  depressing  influence;  a  Dieulafoy,  Potain,  or  other  aspira- 
tor, or  a  trocar  and  cannula,  with  tube  and  basin  of  antiseptic  solution 
for  siphonage.  The  puncture  should  be  made  valvular  by  a  prelimi- 
nary drawing-up  of  the  skin.  The  removal  of  the  fluid  should  be  effected 
slowly  to  allow  of  gradual  expansion  of  the  lung,  and  much  distress,  or 
cough,  or  blood  is  an  indication  for  cessation.  After  the  fluid  is  with- 
drawn, the  puncture  in  the  skin  should  be  sealed  with  a  film  of  cotton 
soaked  in  acetanilid  and  collodion.  The  fluid  should  be  preserved  for 
chemical  and  microscopical  examination.  A  purulent  effusion  may 
occasionally  be  permanently  cured  in  the  child  after  one  or  two  aspira- 
tions (particularly  if  clue  to  the  pneumococcus),  but  this  is  not  to  be 
looked  for  in  the  adult.  The  view  has  been  entertained  by  some  that 
the  tuberculous  lung  is  the  better  for  the  compression  and  splintage  of 
the  effusion ;  such  persons  would,  of  course,  object  to  aspiration. 

Drainage  by  Puncture,  Simple  Incision,  or  Rib-resection  (Thoracot- 
omy) — When  the  fluid  in  the  pleural  cavity  has  been  shown  by  aspi- 
ration, by  the  hypodermic  syringe,  or  otherwise,  to  contain  pus,  drain- 
age, except  occasionally  in  the  child,  should  be  at  once  resorted  to.  If 
this  be  not  done,  nature  will  attempt  to  evacuate  the  abscess-cavity 
either  through  the  lung  or  through  the  third  intercostal  space  a  short 
distance  from  the  sternum.  The  sites  of  election  for  drainage  are  those 
already  mentioned  in  connection  with  aspiration.  Any  bulging  or 
"pointing"  spot  may  properly  be  incised,  but  if  not  suitable  for  drain- 
age should  be  supplemented  by  another  opening  in  one  of  the  aforesaid 
appropriate  positions.  Too  low  a  point  should  not  be  selected,  as  it 
may  be  covered  by  the  diaphragm,  which  rises  after  the  evacuation.  As 
a  general  principle,  it  may  be  affirmed  that  the  point  best  suited  for  long- 
continued  drainage  is  that  calculated  to  be  the  last  to  close,  somewhere 
in  the  equator  of  a  globular  cavity. 

In  draining  by  puncture  all  necessary  or  possible  antiseptic  precau- 
tions, with  regard  to  operator,  field  of  operation,  and  instruments,  hav- 
ing been  duly  and  scrupulously  observed,  and  the  site  selected,  a  short 
incision  may  be  made  by  a  sharp  knife  through  the  skin,  and  a  trocar 
and  cannula,  as  large  as  the  intercostal  space  will  admit,  thrust  sharply 
through  the  muscle-wall  and  the  pleura,  the  thrust  being  thus  made  so 
as  to  perforate  and  not  push  the  serous  membrane  before  the  cannula. 
The  upper  edge  of  the  lower  rib  bounding  the  space  should  be  hugged, 
so  as  not  to  endanger  the  larger  branch  of  the  intercostal  artery,  which 
runs  under  cover  of  the  groove  in  the  lower  border  of  the  upper 
rib. 

When  the  fluid  has  been  evacuated  a  rubber  tube  may  be  passed 
through  the  cannula,  the  latter  is  then  withdrawn,  and  the  former  is 
fixed  in  position  by  safety-pin  or  stitch,  or  by  having  its  free  extremity 
split,  turned  over,  and  fastened  on  the  chest- wall  as  a  flange.  Where 
danger  of  compression  of  the  rubber  tube  exists,  a  metal  sheath  may 
be  properly  employed  for  the  portion  which  lies  between  the  ribs.  The 
tube  should  project  just  within  the  pleura  and  no  more,  since  nothing 
is  gained  by  having  a  foreign  body  within  the  cavity  ;  and  if  it  be  desired 
to  irrigate  subsequently,  a  smaller  tube  may  be  readily  passed  through 
the  larger  one  to  the  bottom  of  the  sac,  if  need  be.     Pulmonary  exer- 


TUBERCULOSIS    OF   THE    SEROUS   MEMBRANES.  2$? 

cises  and  gymnastics  may  be  employed  to  facilitate  drainage.  Both 
pleural  cavities  should  not  be  drained  at  once  ;  or  not  until  some  degree 
of  lung-expansion  has  been  obtained.  In  view  of  the  possibility  of 
syncope,  withdrawal  of  the  fluid  should  be  accomplished  slowly,  re- 
cumbency maintained,  and  stimulants  kept  within  reach.  If  obstruction 
of  the  tube  occur,  as  not  infrequently  happens  from  a  coagulum  of  pus, 
blood,  or  lymph,  it  will  be  convenient  to  have  at  hand  a  hook,  or  bent 
wire,  wherewith  to  effect  its  removal.  Failing  this,  a  probe,  or  director, 
or  stream  of  antiseptic  fluid  will  dislodge  it  backward  into  the  cavity 
again.  Oftentimes  the  width  of  the  intercostal  space  is  insufficient  to 
afford  free  drainage,  and  then  it  becomes  necessary  to  increase  the 
opening  by  the  resection  of  a  portion  of  one  or  more  ribs.  This  may 
be  effected  in  the  case  of  one  rib  by  an  incision  along  the  mid-line  of 
the  rib  down  through  its  periosteum,  which  should  then  be  separated 
to  the  necessary  extent  by  a  raspatory  or  rugine  (two  of  which  should 
be  at  hand,  one  for  the  outer  side,  and  a  more  curved  one  for  the  inner), 
and  a  sufficient  length  of  the  rib  then  removed  either  by  a  Hey's  saw 
supplemented  by  bone-forceps,  or  by  a  rib-shears.  It  is  well  to  secure 
the  intercostal  vessels  by  ligature  or  otherwise,  and  to  remove  the  de- 
tached periosteum  or  thickened  pleura  which  interferes  with  free  drain- 
age and  frequently  reconstructs  the  bone.  If  portions  of  two  (or  more) 
ribs  are  to  be  removed, the  first  incision  maybe  made  in  the  intercostal 
space,  and  the  ribs  dealt  with  as  before ;  or,  as  is  to  be  preferred,  after 
Gould's  manner,  by  a  vertical  incision  covering  both  ribs. 

Drainage  by  Rib-resection. — In  some  cases,  after  free  drainage  of  the 
pleural  cavity  has  been  secured  and  long  maintained,  it  becomes  appar- 
ent that  from  failure  of  lung-expansion  and  diaphragmatic  accommo- 
dation, and  insuperable  rigidity  of  the  costal  wall,  obliteration  of  the 
suppurating  space  cannot  take  place,  the  only  remedy  then  is  to  break 
down  and  remove  the  bony  wall.  This  practice  was  first  suggested  by 
Warren  Stone  of  New  Orleans,  but  popularized  by  Estlander,  under 
whose  name  it  goes.  The  object  is  to  allow  the  granulating  surfaces  to 
fall  together,  to  coalesce,  and  to  cicatrize  ;  and  this  can  be  accomplished 
only  by  the  entire  removal  of  the  bony  barrier.  The  extent  of  the 
operation  will  therefore  depend  on  the  size  of  the  cavity,  and  will 
vary  from  the  exsection  of  portions  of  two  or  three  ribs  to  the  removal 
of  nearly  the  whole  of  the  bony  part  of  all  from  the  second  to  the 
seventh  inclusive.  Above  the  second  it  is  not  well  to  go,  owing  to  the 
relations  of  the  subclavian  vessels  ;  and  below  the  seventh  it  is  not 
usually  necessary,  owing  to  the  adaptability  of  the  diaphragm.  For 
this  operation  general  anesthesia  is  necessary,  and  must  be  conducted 
with  more  than  ordinary  care  and  circumspection.  A  practical  point 
of  some  importance  in  the  operation  is  to  see  that  the  patient  is  not 
turned  too  much  upon  the  sound  side,  whereby  his  respiration  may  be 
seriously  embarrassed,  and,  if  any  communication  with  the  bronchus 
exist,  pus  might  find  its  way  into  the  opposite  bronchial  tract.  Various 
incisions  may  be  used  to  gain  access  to  the  bone  to  be  removed. 
Godlee  recommended  a  large  U-shaped  incision,  with  the  base  upward, 
allowing  a  large  flap  to  be  turned  up  and  the  costal  wall  well  exposed; 
it  is  apt  to  be,  however,  attended  with  a  great  deal  of  hemorrhage. 
Jacobson  proposed  several  similar  smaller  ones.     Estlander  employed 

17 


258  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

an  intercostal  incision,  through  which  he  removed  a  rib  above  and  one 
below,  and  made  as  many  such  incisions  as  the  given  case  required. 
The  writer  has  found  Pearce  Gould's  free  vertical  incision  much  the 
best,  and  through  two  such — an  anterior  and  a  posterior — all  the  ribs 
may  be  removed,  from  the  angles  to  the  cartilages. 

Tuberculosis  of  the  peritoneum  is  met  with  in  three  different 
forms,  according  to  Osier ;  first,  as  part  and  parcel  of  general  miliary 
tuberculosis;  second, a  chronic  fibrous  form,  subacute  from  the  outset, 
attended  by  little  or  no  exudation,  and  presenting  hard  and  pigmented 
nodules  ;  third,  a  more  or  less  chronic,  caseous,  and  ulcerating  form, 
characterized  by  a  growth  of  large  tuberculous  masses,  tending  to 
caseate  and  ulcerate,  forming  adhesions  and  communications  between 
adjacent  intestinal  coils,  and  accompanied  by  a  serous,  seropurulent,  or 
purulent  exudation,  not  infrequently  localized  or  sacculated.  It  is,  of 
course,  of  the  subacute  or  chronic  variety  when  the  affection  comes 
into  the  hands  of  the  surgeon,  for  local  treatment  cannot  be  of  service 
in  the  presence  of  general,  acute,  miliary  tuberculosis. 

The  diagnosis  of  tuberculous  peritonitis,  as  of  tuberculous  affec- 
tions of  the  other  serous  membranes,  is  made  chiefly  by  exclusion ; 
but  the  family  and  personal  history  may  be  of  importance.  If  the 
affection  of  the  membrane  be  primary — that  is  to  say,  if  the  tubercle 
bacilli  floating  in  the  blood  be  arrested  in  the  vessels  of  the  membrane 
itself  and  there  develop,  we  may  have  simply  an  ascites  of  slow  and 
insidious  development,  without  rise  of  temperature  or  material  disturb- 
ance of  the  general  health.  Under  such  circumstances  we  can  only 
arrive  at  a  diagnosis,  before  exploration,  by  excluding  the  usual  causes 
of  ascites,  such  as  diseases  of  the  liver,  malignant  tumors  of  the  peri- 
toneum and  viscera,  and  chronic  valvular  affections  of  the  heart. 

On  abdominal  section,  exit  is  given  to  a  clear,  straw-colored,  or 
sometimes  sanguinolent  fluid,  and  the  serous  surfaces  are  found  to  be 
studded  more  or  less  generally  with  white  or  yellow  tubercles,  which 
may  be  here  and  there  massed  into  tumors  of  considerable  size. 
Sometimes  such  masses,  if  very  large,  can  be  felt  by  bimanual  palpation 
per  rectum  or  per  vaginam,  and  may  simulate  any  conceivable  growth. 
If,  as  not  infrequently  happens,  the  peritoneal  fluid  be  localized  by  pre- 
existing or  simultaneously  developed  adhesions,  the  resemblance  to 
any  of  the  solid  or  fluid  growths  peculiar  to  the  locality  may  be  very 
great.  Thus,  if  confined  to  the  epigastric  or  hypochondriac  regions, 
we  may  have  very  accurate  simulations  of  hydatid  cysts,  cysts  of  the 
pancreas,  enlarged  gall-bladder,  or  hydrosalpinx  or  pyonephrosis.  If 
the  lower  half  of  the  abdomen  alone  be  involved,  suspicions  of  preg- 
nancy, ovarian  tumor,  hydrosalpinx  and  pyosalpinx,  or  pelvic  abscess 
may  arise,  and  they  may  be  very  difficult  to  settle  without  a  celiotomy 
or  paracentesis.  In  deciding  upon  such  cases,  due  weight  must  be 
given  to  the  history  and  course;  and  the  diagnostic  value  of  tuberculin 
should  be  tested.  For  the  majority  of  these  conditions,  however,  celi- 
teomy  is  indicated  and  necessary,  and  the  operation  for  discovery  may 
be  readily  converted  into  the  means  of  cure. 

When  the  great  omentum  is  the  seat  of  tuberculous  deposit,  it  is 
frequently  converted  into  a  firm  fibrous  band  or  cord,  stretching  across 
the  abdomen  in  or  just  above  the  region  of  the  umbilicus,  and  it  some- 


TUBERCULOSIS  OF  TENDONS,   TENDON-SHEATHS,  AND  BURS.E.     259 

times  bears  a  strong  resemblance  to  the  solid  neoplasms  of  the  stomach, 
pancreas,  and  retroperitoneal  glands. 

Tuberculous  ulceration  of  the  stomach,  small  intestine,  appendix, 
colon,  or  mesenteric  glands  may  give  rise  to  implication  of  the  peritoneum 
by  direct  extension,  or  to  peritonitis  by  perforation,  which  peritonitis 
would  be  of  the  acute  type  and  demand  immediate  operation,  during 
the  performance  of  which  the  ruptures  would  have  to  be  closed  by 
suture,  preferably  after  the  excision  of  the  implicated  part,  followed,  if 
necessary,  by  anastomosis. 

The  Fallopian  tube  is  sometimes  the  primary  focus,  giving  rise  to 
the  extension  of  the  tuberculous  process  to  the  peritoneum  ;  and  Osier 
estimates  that  the  tube  is  involved  in  from  30  to  40  per  cent,  of  the 
cases  of  tuberculous  peritonitis,  a  fact  which  may  afford  an  explanation 
of  the  far  greater  frequency  of  its  occurrence  in  the  female. 

The  radical  treatment  of  tuberculous  peritonitis  is  as  simple  as  it 
is  for  the  most  part  satisfactory,  consisting  generally  of  a  mere  celiot- 
omy, performed  with  great  care,  of  course,  owing  to  the  liability  to 
intestinal  and  other  adhesions.  After  evacuation  of  the  fluid  has  been 
accomplished,  in  the  great  majority  of  cases  the  abdominal  wound 
should  be  promptly  sutured  without  flushing  or  drainage.  If  a  drain- 
age tube  be  inserted,  provision  for  a  late  or  secondary  suture  should 
be  made  by  passing  one  or  more  sutures  through  the  site  of  the  drain- 
age tube,  leaving  them  to  be  tied  after  its  removal  in  twenty-four  or 
forty-eight  hours.  Some  dust  the  peritoneal  surfaces  with  (sterilized) 
iodoform,  or  introduce  an  emulsion  of  iodoform  in  glycerin  (sterile),  the 
dose  of  40  grains  (2.6  gm.)  of  iodoform  being  on  no  account  exceeded, 
since  absorption  of  more  than  that  amount  has  been  known  to  prove 
fatal.  When  large  cheesy  masses  have  been  met  with,  it  has  been  pro- 
posed to  deal  with  these  by  ignipuncture  (thermocautery),  followed  by 
iodoformization.  In  such  cases  drainage  may  be  advisable  for  a  short 
period.  In  using  iodoform  gauze  as  a  drain,  the  writer  has  found  it 
preferable  to  leave  it  in  situ  several  days,  a  procedure  which  greatly 
facilitates  its  removal.  Much  discussion  has  arisen  as  to  the  modus 
medcndi  of  celiotomy  in  tuberculous  peritonitis.  The  suggestion  of 
Lauenstein  that  the  admission  of  atmospheric  air  or  of  sunlight  with 
some  occult  influence,  or  of  air  containing  germs  or  toxins  inimical  to 
the  Bacillus  tuberculosis,  or  the  removal  of  accumulated  ptoma'ins,  are 
all  inadequate  to  the  explanation.  It  seems  not  improbable  that  the 
stimulus  to  the  lymphatic  and  blood-circulations,  incident  and  reaction- 
ary to  the  trauma,  and  the  sudden,  altered,  physical  conditions  of 
pressure,  so  beneficial  in  simple  cases  of  hydrocele  and  other  like  effu- 
sions, may  exert  a  similar  benign  influence  in  these  conditions  also. 


TUBERCULOSIS  OF  TENDONS,  TENDON-SHEATHS,  AND  BURSAE. 

Tuberculosis  of  tendon-sheaths  is  not  common,  constituting  only 
I  or  2  per  cent,  of  cases  of  local  tuberculosis.  It  may  be  primary  or 
secondary,  the  secondary  form,  resulting  from  extension  of  the  disease 
from  neighboring  bones  and  joints,  being  much  more  common.  The 
affection  presents  itself  in  three  forms.  The  first  is  a  fungus  form,  in 
which  the  sheath  of  the  tendon  is  lined  by  a  layer  of  granulations,  ^ 


26o  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

to  |  of  an  inch  (2.1 1-6.35  mm.)  in  thickness;  while  a  thinner  layer 
covers  the  tendon  itself  and  sometimes  perforates,  dissociates,  and  dis- 
integrates its  bundles.  This  imparts  to  the  palpating  finger  a  sensation 
of  gelatinous  semi-fluctuation,  and  synovial  effusion  may  be  entirely 
wanting.  In  the  second  form  the  fibrinous  inflammatory  properties  of 
the  bacillus  insisted  upon  by  Konig  are  strongly  manifested,  and  the 
granulations  are  converted  into  large,  white,  fibrous  masses,  variously 
termed  "  rice  bodies "  or  corpora  oryzoidea,  "  melon-seed  bodies," 
"  foreign  bodies,"  "  loose  cartilages,"  etc.  In  this  form  copious  syno- 
vial effusion  is  likely  to  be  found,  though  not  invariably,  and,  in  addi- 
tion to  free  fluctuation,  the  rubbing  of  these  bodies  against  one  another 
is  readily  perceived.  In  the  third  form  a  simple  dropsical  effusion  into 
the  tendon-sheath,  "  a  hygroma,"  occurs  ;  and  we  get  an  oval,  elongated, 
fluctuating  swelling  in  the  direction  of  the  tendon,  if  the  affection  be 
single;  or  of  the  tendons,  if  multiple — the  so-called  simple  and  com- 
pound ganglia. 

The  favorite  seats  of  this  affection  are  the  flexor  and  the  extensor 
tendons  about  the  wrist-joint,  the  peroneal  tendons,  and  the  tendons 
about  the  knee.  The  possibility  of  communication  with  the  synovial 
membrane  of  the  adjacent  joints  must  always  be  borne  in  mind 
in  these  cases.  Occurring  in  the  forearm  and  palm,  an  hour- 
glass swelling  is  often  produced,  owing  to  the  constriction  of  the 
annular  ligament,  beneath  which  the  fluid  passes  readily  from  the  one 
swelling  to  the  other. 

In  the  dry  form  ulceration  or  necrosis  may  take  place,  and  the  dis- 
ease spread  thus  from  the  tendon-sheaths  to  the  fascial  and  muscle 
planes.  The  tuberculous  character  of  the  contents  having  been  de- 
stroyed by  the  fibrosis,  is  not  always  demonstrable  by  the  microscope, 
but  proof  will  generally  be  afforded  by  inoculation  experiment.  The 
disease  is  painless,  slow,  and  insidious  in  its  origin  and  progress,  and 
often  exists  long  before  advice  is  sought,  weakness  of  the  joints  and 
fatigue  being  chiefly  complained  of. 

The  treatment  consists  in  the  evacuation  of  the  fluid  and  fibrous 
bodies,  followed  by  scraping  off  the  granulation-layer,  vigorous  rubbing 
of  the  surfaces  with  iodoform  gauze,  and  the  injection  of  iodoform 
emulsion,  after  which  suturing,  antiseptic  dressing,  compression,  and 
splintage  will  usually  suffice.  Sufficiently  free  incisions  must  be  made 
under  rigid  antisepsis  to  admit  of  thorough  carrying  out  of  this  plan 
of  treatment. 

In  the  dry  and  ulcerating  form  a  similar  line  of  action  may  be 
adopted,  but  it  will  generally  be  necessary  to  make  a  clean  and  thor- 
ough dissection  of  the  tendons  and  sheaths  involved,  sometimes  with 
autoplasty  of  the  tendons,  in  doing  which  the  bloodless  method  of 
Esmarch  will  be  indispensable,  and  the  relation  of  the  backs  of  the 
tendon-sheaths  to  the  synovial  sacs  of  the  underlying  joints  must  be 
constantly  borne  in  mind.  The  occurrence  of  sepsis  would  certainly 
be  fatal  to  the  integrity  of  the  limb,  if  not  to  the  life.  It  is  surprising 
what  good  results  are  obtained  by  a  complete  and  successful  ablation 
of  the  disease  tissue,  and  how  perfectly  the  tendon-sheaths  will  be 
restored. 

What  has   been   said  of  tendon-sheaths  is   also   applicable  to  the 


TUBERCULOSIS    OF   THE    GENITO- URINARY  ORGAXS.  26 1 

bursae,  and  the  only  thing  to  be  said  in  addition  is  to  enforce  the 
recommendation  of  Professor  John  Chiene  of  a  semilunar  incision, 
with  reflection  of  a  flap  in  dissecting  out  the  bursal  sac. 


TUBERCULOSIS  OF  MUSCLES  AND  FASCIAE. 

As  mentioned  in  the  preceding  section,  tuberculosis  may  extend  by 
contiguity  from  joint  and  tendon  sites  to  the  fascial  and  muscle  planes. 
It  may  also  occur  primarily  in  these  situations  ;  but,  so  far  as  muscle 
is  concerned,  so  rarely  as  to  be  a  curiosity.  Muscle  infected  with  tuber- 
culosis has  a  grayish  look  and  a  hardened  feel.  In  the  fascia,  on  the 
other  hand,  primary  tuberculosis  is  by  no  means  rare,  and  secondary 
infection  very  common.  The  bacillus  has  a  predilection  for  the  fascial 
planes,  and  the  resulting  granulation-tissue  spreads  along  and  over 
them  with  facility  and  rapidity,  dipping  into  all  their  ramifications  and 
dissecting  out  the  contents.  When  coagulation-necrosis  and  liquefac- 
tion of  this  tissue  occurs,  widespread  and  tortuous  "  cold  abscesses  " 
result. 

The  principles  of  treatment  are  already  enunciated ;  and  thorough- 
ness in  their  application  is  the  key-note  of  success. 

For  Tuberculosis  of  the  Bones  and  Joints  see  Chapters  XIX. 
and  XX. 

TUBERCULOSIS  OF  THE  GENITO-URINARY  ORGANS. 

(So  far  as  the  female  genito-urinary  organs  are  concerned,  this  sub- 
ject will  be  considered  in  Chapter  XXI.,  Vol.  II.) 

Tuberculosis  of  the  penis  is  an  exceedingly  rare  affection, 
except,  perhaps,  for  those  cases  of  inoculation  in  infants  in  the  Hebrew 
rite  of  circumcision,  of  which  quite  a  number  have  been  recorded, 
mostly  by  continental  writers  (Lyndmann,  2  cases  ;  Lehmann,  10  cases  ; 
Eve,  2  cases).  The  wounds  or  scars  become  the  site,  first,  of  nodules,  then 
of  unhealthy  spreading  ulcers,  and  in  two  or  three  weeks  the  inguinal 
glands  are  affected,  some  of  which  suppurate,  and  some  do  not. 

Tuberculosis  urethras  is,  according  to  Kaufmann,  always  part  of  a  generalized 
tuberculosis,  and  occurs  secondarily  by  infection  from  the  bladder  or  prostate.  The  pros- 
tatic portion  is  most  frequently  affected,  less  often  the  membranous  portion.  Vettesen  has 
reported  tuberculous  ulceration  of  the  meatus  in  a  phthisical  patient  aged  seventeen.  An 
indurated  ulcer  occupied  one  side  of  the  meatus  and  extended  into  the  fossa  navicularis  ;  the 
glands  of  the  groin  were  enlarged,  as  were  also  the  epididymis  and  prostate  ;  and  bacilli 
were  found  in  the  ulcer.  The  autopsy  showed,  in  addition,  tuberculosis  of  the  right  kidney, 
bladder,  prostate,  and  the  bulbous  urethra. 

Englisch  has  described  a  tuberculous  pcri-urcthritis  in  the  deeper 
portions  of  the  urethra.  It  may  exist  either  inside  or  outside  the 
deeper  layer  of  the  superficial  fascia.  "  It  begins  with  a  discharge  of  a 
chronic  character  from  the  urethra,  followed  later  by  the  formation  of 
perineal  abscesses  and  fistulas."  Some  of  the  cases  of  incurable  "water- 
ing-pot "  perineum  are  doubtless  tuberculous  in  their  nature.  Lang- 
hans  reports  a  case  of  polypoid  tuberculosis  situated  in  the  urethra 
about  one  inch  from  the  mouth.  The  autopsy  showed  general  uro- 
genital tuberculosis. 

Senn  mentions  a  case  of  tuberculous  ulceration  of  the  dorsum  of  the  penis 

which  might  easily  have  been  mistaken  for  a  chancre.    Kraske  reports  a  case  in  a  man  aged 


262  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

forty-nine,  in  whom  a  tuberculous  ulcer  occurred  upon  the  dorsum  oftheglans  penis.  There 
were  two  irregularly  shaped  ulcers,  the  bases  having  a  yellowish,  cheesy  appearance,  with 
here  and  there  a  tendency  to  the  formation  of  granulations,  yielding  a  thin  secretion.  The 
edges  were  undermined,  and  the  ulcers  communicated  with  one  another.  The  patient  was 
healthy,  with  no  evidence  of  tuberculosis  in  the  epididymis,  testicle,  prostate,  or  elsewhere. 
The  ulcers  were  of  three  months'  standing  when  admitted  in  the  Freiburg  clinic,  they  ex- 
tended deeply  into  the  glands,  amputation  was  resorted  to,  and  microscopical  examination 
showed  both  typical  giant  cells  and  bacilli.  The  deeper  tissues  were  more  affected  than  the 
superficial,  evidencing  a  blood-infection  rather  than  a  local  inoculation.  Looten  has  pub- 
lished a  case  of  Founder's,  a  man  aged  twenty-four  with  lupus  ulcer  of  the  glans  penis. 

Lupus  of  the  penis  is  a  rare  affection,  and  generally  has  the  disease  coexistent 
elsewhere — on  the  face,  lobes  of  the  ears,  or  legs.  Jacobson  has  seen  only  one  case,  in  a 
young  patient  with  extensive  affection  of  the  nose  and  face.  Hutchinson  records  one  on 
the  prepuce  in  which  he  circumcised.  He  explains  the  rarity  of  the  affection  by  saying 
that  lupus  commonly  attacks  those  parts  of  the  body  exposed  to  thermal  changes  ;  and  the 
genitals  being  kept  uniformly  warm  by  the  clothing  are  more  exempt. 

To  distinguish  lupus  of  the  penis  from  epithelioma  two  points  should  be  borne  in  mind — 
lupus  begins  during  boyhood  or  youth,  epithelioma  is  a  disease  of  old  age  ;  lupus  advances 
slowly,  leaving  cicatrices  ;  epithelioma  more  rapidly,  tending  to  glandular  involvement  and 
ulceration. 

Treatment  consists  in  ablation  where  possible,  and  in  currettage  and  iodoformization 
where  this  is  inadmissible. 

Tuberculosis  of  the  Prostate.— Korzyurcki  asserts  that  in 
genitourinary  tuberculosis  the  prostate  is  never  missed ;  but  whatever 
may  be  the  primary  focus  this  gland  early  manifests  infection.  Nearly 
all  the  later  authorities  concur  in  this  statement,  whether  they  agree 
with  Virchow,  Ziegler,  Forster,  or  Steinthal  in  thinking  that  tubercu- 
losis of  the  genito-urinary  tract  always  begins  in  the  kidney,  or  whether 
they  hold  with  Rokitansky,  Birch-Hirschfeld,  Bardenhauer,  and  others, 
that  the  initial  point  is  the  epididymis  or  prostate.  In  view  of  the  sit- 
uation of  the  prostate  gland,  one  can  readily  conceive  that  primary 
infection,  except  by  way  of  the  blood-channels,  must  be  exceedingly 
rare.  But  its  location  at  the  point  of  junction  of  the  urinary  and  geni- 
tal systems  with  their  blood-vascular  and  lymphatic  channels  renders 
it  equally  liable  to  secondary  infection  from  both  sources. 

Tubercle  bacilli  which  have  been  cultivated  in  an  intestinal  gland 
and  found  their  way  into  the  general  peritoneal  cavity  may  readily  drop 
into  the  rectovesical  pouch,  and  thence  invade  the  prostate  and  peri- 
prostatic tissue,  either  directly  or  through  the  lymph-channels.  There 
is  some  reason  for  believing  that  this  may  be  the  explanation  of  many 
cases  of  seeming  primary  infection  of  the  prostate  gland. 

The  diagnostic  points  may  be  enumerated  as  a  urethral  discharge, 
consisting  of  mucus,  pus,  epithelium,  caseous  masses,  and  bacilli — one 
or  all,  according  to  the  stage  ;  frequency  of  micturition  ;  pain  on  instru- 
mentation ;  weight,  and  dragging,  and  tenderness  in  the  perineum  ; 
enlargement;  bosselation ;  softened  foci  detectable  per  rectum;  the 
presence  of  tubercle  elsewhere  ;  the  existence  of  abscess  ;  the  occur- 
rence of  non-healing  sloughy  ulcers  and  multiple  fistulae.  Bryson  lays 
stress  upon  distinct,  hard,  pea-sized  nodules  in  the  vesicoprostatic  veins, 
and  Cabot  found  corresponding  nodules  in  the  lymphatic  glands  in  the 
same  situation.  When  the  nodules  are  few,  small,  and  peripheral,  or 
in  the  capsule,  they  may  be  void  of  symptoms ;  dependence  must  then 
be  placed  upon  the  signs. 

The  prostaticovesicular  junction  is  a  favorite  point  for  nodulation.  Pain 
in  coitus  may  probably  exist,  and  currant-jelly  semen  be  discharged. 

The  treatment  is  general  and  local.     In  addition  to  the  more  ordi  - 


TUBERCULOSIS   OF   THE    GENITO-URINARY   ORGANS.  263 

nary  remedies,  guaiacol,  arsenic,  and  iodoform  have  been  recommended. 
Locally,  guaiacol  may  be  rubbed  into  the  perineum,  suprapubic  region, 
and  the  epididymis.  Ulcers  and  abscesses  must  be  treated  upon  gen- 
eral principles.  In  acute  cases  Milton  affirms  that  he  derived  benefit 
from  tartar  emetic  in  ^  grain  (0.0027  gm.)  doses  every  three  hours. 
Instrumentation  of  all  kinds  should  be  rigidly  avoided,  as  it  serves 
only  to  aggravate  the  symptoms. 

Tuberculosis  of  the  vesiculae  seminales  is  almost  never  seen, 
except  as  secondary  to  disease  in  neighboring  organs  ;  but  that  it  occa- 
sionally occurs  there  primarily,  as  Soloweitschik's  case  shows,  cannot 
be  denied. 

The  symptoms  are  frequency  of  micturition,  great  sexual  excitability 
followed  by  impotence  or  sterility,  with  frequent  emissions  of  blood- 
stained semen  ;  in  the  later  stages,  abscesses  and  perineal  fistulse.  In 
one  case  Weichselbaum  found  a  large  vein  of  the  pudendal  plexus  per- 
forated by  a  tuberculous  abscess  of  the  vesicle. 

The  diagnosis  must  be  made  by  attention  to  the  general  history, 
the  local  symptoms,  the  discovery  of  nodes  and  dilatations  by  rectal 
examination,  the  presence  of  bacilli  in  the  semen — which  is  asserted 
by  some  never  to  occur — and  the  intolerance  of  instrumentation. 

Treatment  is  general  and  local.  The  local  treatment  consists  in 
"stripping"  either  by  the  finger  of  the  surgeon  or  by  Feleki's  or 
Swinburne's  instrument  devised  for  the  purpose,  which  is  said  to  be 
more  effective  and  less  unpleasant.  Ablation  of  the  vesicle  has  been 
practised  in  one  case  by  Ullmann,  employing  Zuckerkandl's  semilunar 
incision  through  the  perineum,  with  the  base  downward. 

Roux  of  Paris  records  two  cases  in  which  the  testicle  and  vas  were 
first  removed,  then  a  perineal  incision  was  made,  the  vesicle  being 
pushed  into  the  incision  from  the  rectum  and  thus  removed. 

Tuberculosis  of  the  Testis,  Epididymis,  and  Vas  Deferens. 
— Synonyms. — Tubercular  epididymitis  ;  Tuberculosis  testis  ;  Tubercu- 
lar orchitis  ;  Tubercular  sarcocele  ;  Phthisis  testis  ;  Strumous  or  scrof- 
ulous disease  of  the  testis  ;  and  Scrofulous  orchitis.  Two  varieties  are 
presented  : 

(a)  The  general  miliary  tuberculosis,  which  is  rare. 

(/9)  The  form  characterized  by  discrete  craggy  or  nodose  deposits. 

The  most  frequent  seat  is  the  epididymis,  of  which  the  globus  major 
is  generally  attacked,  according  to  most  authorities,  but  according  to 
Erichsen  and  H.  Eilers,  the  globus  minor.  The  disease  spreads  by 
creeping  along  the  mucous  surfaces  to  the  testis  or  to  the  vas  deferens. 
The  reason  assigned  for  the  more  frequent  early  implication  of  the 
epididymis  is,  according  to  Salzmann,  that  the  vessels  are  smaller  and 
more  tortuous,  and  that  the  spermatic  artery  breaks  up  into  two 
branches  opposite  the  epididymis.  If  the  infection  takes  place  from 
below,  per  iirctliram,  it  would  follow  that  the  globus  minor  should  be 
first  affected,  as  in  the  corresponding  affection  by  the  gonococcus.  Later 
on,  the  disease  may  spread  to  the  vesiculae  seminales,  prostate,  bladder, 
and  kidney,  or  it  may  give  rise  to  general  or  pulmonary  tuberculosis. 
Salleron,  however,  in  a  series  of  5  1  cases,  found  other  organs  infected 
in  only  1,  and  but  2  deaths  in  these  51  cases. 

So  far  as  age  is  concerned,  the  disease  usually  occurs  in  early  adult 


264  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

life ;  but  it  is  not  seldom  met  with  in  infancy  and  in  old  age,  at  which 
latter  period  its  virulence  seems  to  be  much  diminished.  Giraldes  found 
tubercle  of  the  testicle  in  an  infant  at  term.  Jullien  in  16  cases  records 
that  6  were  infants  under  one  year.  Julius  Dreschfeld  records  a  case 
of  congenital  tuberculosis  of  the  testicle;  and  Hutinel  and  Deschamps 
think  the  affection  is  as  common  before,  as  after,  puberty,  and  believe 
that  it  frequently  commences  in  the  peritoneum. 

Three  stages  have  been  described  : 

(«)  Of  deposit ;  (/3)  of  caseation,  softening,  and  abscess ;  (y)  of 
fistulae  and  fungus.  The  symptoms  will  vary  with  the  stage.  In  that 
of  deposit  they  may  be  nil ;  but  manipulation  will  reveal  the  existence 
of  one  or  several  hard,  characteristic  nodules  in  the  part  affected,  com- 
monly the  epididymis. 

Thickening  of  the  vas  deferens,  particularly  at  its  extremities,  is 
strongly  corroborative.  In  the  stage  of  caseation,  the  hard  nodules 
will  be  replaced  by  fluctuant  swellings ;  and  the  stage  of  fistula  and 
fungus  then  declares  itself. 

The  diagnosis  from  simple  or  gonorrheal  epididymitis  is  made  by 
the  history,  the  location  of  the  swelling,  the  absence  of  pain,  and  the 
wooden  hardness ;  from  orchitis  by  similar  signs  transferred  to  the 
testicle ;  from  syphilitic  sarcocele,  or  gumma,  by  the  history,  by  the 
implication  of  the  testicle  rather  than  the  epididymis,  by  the  special  loss 
of  testicular  sensation  in  gumma,  by  the  absence  of  hydrocele,  and  by 
the  tendency  to  the  formation  cf  fistulae.  According  to  Jacobson, 
hydrocele  occurs  in  about  one-third  of  the  cases  ;  the  quantity  of  fluid 
is  small,  of  unusual  density,  and  contains  flocculi  and  shreds  (Reclus). 

The  prognosis  depends  upon  associated  deposits  and  the  general 
condition.  The  local  disease  may  exist  for  several  years  without  im- 
pairment of  the  general  health. 

The  treatment  is  that  of  tuberculosis  in  general.  Locally,  incision, 
scraping,  and  iodoformization,  with  subsequent  dressing  with  balsam  of 
Peru.  Sclerogenesis,  by  the  injection  of  weak  solutions  of  chlorid  of 
zinc  in  the  neighborhood  of  the  foci,  is  recommended  by  Lannelongue, 
and  the  cautery  by  Verneuil.  Reboul  of  Marseilles  advocates  injec- 
tions of  naphthol-camphor,  and  records  three  successful  cases  in  which 
4  or  5  drops  (0.24-0.3  c.c.)  were  injected  daily  into  the  thickened 
tissues  for  eight  or  ten  days.  Castration  has  been  frequently  practised 
successfully.  If  ulceration  has  occurred,  the  tunica  vaginalis  and 
infected  skin  should  likewise  be  removed,  and  the  cord  ligated  as 
high  as  possible.  If  both  testicles  are  simultaneously  involved,  most 
authorities  discountenance  castration ;  but  very  good  results  have  been 
obtained  by  the  less  radical  methods  above  mentioned. 

Tuberculosis  of  the  bladder  is  rare  as  a  primary  affection. 
When  it  occurs,  the  trigonal  submucosa  is  the  most  likely  seat, 
whether  it  is  brought  by  the  circulating  blood  or  has  migrated  from 
the  peritoneal  cavity.  According  to  statistics,  it  seems  to  be  three 
times  more  common  in  men  than  in  women.  Should  infection  take 
place  from  without,  however,  the  short  and  direct  passage  afforded  by 
the  female  urethra  would  seem  to  render  women  more  liable  to  the 
disease. 

As  a  secondary  affection,  tuberculosis  may  occur  in  the  bladder, 


TUBERCULOSIS   OF  THE    GENITO-URINARY  ORGANS.  265 

either  by  ascending  from  the  prostate  and  the  epididymis  or  by  descend- 
ing from  the  kidney,  whence  the  germ  may  be  brought  either  in  the 
creeping  form  along  the  mucous  surfaces,  or  in  suspension  in  the 
urinary  secretion  from  the  pelvis  of  the  kidney. 

The  symptoms  closely  resemble  those  of  vesical  calculus.  It  is 
most  frequent  in  the  young,  from  fifteen  to  twenty-five  years  of  age ; 
and,  according  to  Bryson,  most  of  the  affected  will  present  a  history 
of  masturbation  upon  which  they  lay  great  stress,  with  a  family  one  of 
tuberculosis  or  cancer;  and  a  personal  one  of  enuresis  up  to  four  or 
five  years  of  age.  Frequency  of  micturition  is  the  first  prominent 
symptom,  gradually  increasing,  first  by  day,  and  later  also  by  night, 
as  a  distention-reflex,  with  blood  at  the  end  of  the  act.  Pain  in  the 
mid-penis  is  frequently  complained  of,  with  vesical  tenesmus,  and  occa- 
sional sudden  stoppage  of  the  stream,  with  increase  of  distress.  In 
active  cases  there  may  be  sloughing  of  the  mucosa  with  brisk  transient 
hemorrhage. 

The  differential  diagnosis  from  stone  may  be  made  by  the  following 
points,  according  to  Bryson  :  1.  The  absence  of  a  history  of  renal  cal- 
culus. 2.  Less  effect  of  exercise  upon  vesical  irritability.  3.  Situation 
of  pain  in  the  mid-penis,  not  passing  forward  under  the  glans.  4.  Sud- 
den arrest  of  the  stream  by  voluntary  contraction  of  the  compressor 
urethrae  to  relieve  the  pain  of  passage  along  the  urethra,  and  not  by 
the  sudden  blockage  of  the  internal  meatus  by  a  stone.  5.  The  more 
rapidly  increasing  nocturnal  frequency,  and  its  clear  dependence  on  a 
distention-reflex.     6.  The  growing  evidence  of  a  contracting  bladder. 

The  guarded,  careful  use  of  the  cystoscope  and  bacteriological  in- 
vestigation of  the  urinary  sediments  will,  of  course,  afford  the  most 
positive  and  useful  information.  When  infection  takes  place  by  way  of 
the  urinary  current  from  the  pelvis  of  the  kidney,  the  microscope  and 
bacteriological  investigation  will  afford  the  earliest  information.  If  the 
disease  creep  in  by  continuity  along  the  ureter,  it  will  likely  follow  the 
corresponding  trigonal  limb,  and  may  not  give  rise  to  any  symptoms, 
but  should  be  detected  by  the  cystoscope.  This  latter  form  oftentimes 
closely  simulates  renal  calculus.  In  all  cases  of  surface-infection  the 
symptoms  appear  early  after  invasion ;  but  when  infection  is  from  with- 
out— i.  e.,  submucously — the  occurrence  of  symptoms  is  often  long 
delayed,  and  considerable  advance  may  be  made  before  the  patient  is 
aware  of  anything  amiss.  The  cystoscope,  however,  is  often  equal  to 
the  detection  of  these  cases  also,  if  attention  be  directed  to  the  bladder. 

In  the  cases  of  primary  invasion  of  the  middle  coat  of  the  bladder 
by  way  of  the  blood-vessels,  symptoms  are  almost  entirely  wanting, 
but,  when  they  do  appear,  they  are  enumerated  by  Bryson  as  consist- 
ing of:  1.  Weakening  of  the  detrusor-muscle  plane,  manifested  by  a 
slowness  to  start  the  stream,  a  weakness  of  flow,  and  difficulty  in 
emptying  the  bladder.  2.  The  accumulation  of  some  residual  urine  in 
the  later  stages.  3.  A  gnawing  pain  behind  the  pubes  when  the  blad- 
der is  distended,  not  quickly  relieved  by  micturition.  4.  Slight  hem- 
orrhages from  overdistention.  Here  there  is  no  frequency,  no  pus,  no 
bacilli,  and  seldom  blood ;  and,  when  occurring  in  later  life,  the  symp- 
toms may  closely  mimic  prostatic  obstruction. 

The  bladder  is  sometimes  invaded  from  infected  seminal  vesicles. 


266  INTERNATIONAL    TEX 'J'- HOOK  OF  SURGERY. 

Under  such  circumstances  calculus  is  closely  simulated,  and  this  leads 
to  very  injurious  instrumentation.  "  Owing  to  the  infiltration-rigidity, 
distention  is  interfered  with  and  frequent  micturition  results,  the  bladder 
capacity  being  limited  to  4  or  5  ounces  (1  5-18.5  c.c).  When  the  bladder 
is  partly  empty,  relief  ensues,  followed  by  recurrence  of  the  suffering 
as  it  contracts  down  further,  thus  bending  the  stiffened  seminal  vesicles 
or  compressing  the  inflamed  internal  meatus,  giving  rise  to  tenesmus 
and  the  extrusion  of  a  few  drops  of  blood,  the  distress  slowly  subsiding 
as  the  bladder  partly  fills  again  "  (Rryson). 

Coming  from  the  prostate,  the  infection  creeps  rather  uniformly  up 
from  the  anterior  angle  of  the  trigonum,  probably  by  the  lymphatics 
of  the  submucous  coat.  The  symptoms  are  those  of  cystitis  of  the 
neck  with  bright  transitory  hemorrhages ;  per  rectum,  an  unusual  sen- 
sitiveness of  the  intervesicular  space ;  distention-reflex  is  marked,  nod- 
ules will  be  felt  in  the  wall  below  the  anterior  angle,  and  nodules  in 
the  prostate. 

In  making  a  diagnosis,  cystoscopy  should  be  practised  with  the 
utmost  precautions ;  for  all  instrumentation  leads  to  aggravation  of 
the  symptoms. 

Treatment. — Bryson  condemns  nearly  all  of  the  recognized  forms 
of  treatment  except  general  and  climatic,  and  concludes :  "  On  the 
whole,  surgery  offers  very  little  to  these  patients,  and  meddlesome 
surgery  does  much  harm." 

Henry  Morris  agrees  that  local  treatment  is  contraindicated  except 
in  the  later  stages.  The  writer  believes  that  he  has  found  much  benefit 
from  median  perineal  cystotomy,  followed  by  iodoformization  and  dis- 
infection with  methyl  blue,  and  from  the  rest  which  the  continuous 
drainage  affords. 

Catheterization  is  not  necessary  to  local  medication,  for  sedative  and 
antiseptic  fluids  can,  with  a  little  practice,  be  injected  per  urethram 
alone. 

Tuberculosis  of  the  Kidney. — Tuberculosis  of  the  kidney  oc- 
curs in  two,  or,  perhaps,  three  forms.  The  first  is  part  and  parcel  of  a 
general  miliary  tuberculosis,  with  which  the  surgeon  has  no  concern. 
The  second  a  form  of  localized  miliary  tuberculosis,  in  which  one  or 
many  points  of  both  kidneys  may  be  affected,  the  contagium  being  car- 
ried by  the  blood-stream  and  settling  in  the  capillaries  surrounding 
the  tubules  of  Ferrein,  there  giving  rise  to  the  development  of  granu- 
lation-tissue, which  subsequently  undergoes  coagulation-necrosis,  lique- 
faction, and,  in  the  presence  of  pyogenic  organisms,  pus-formation. 
The  other  form  is  a  tuberculous  pyelitis,  or  pyelonephritis,  or  nephro- 
phthisis, which  may  occur  primarily,  or  from  infection  by  spinal  tuber- 
culosis, or  by  an  ascending  creeping  process  from  the  lower  urinary 
tract.  The  disseminated  tuberculosis  is  more  common  in  children,  and 
is  bilateral.  A  tuberculous  pyelitis  often  affects  one  kidney  only,  and 
is  met  with  commonly  after  the  age  of  puberty. 

In  all  cases  of  cortical  or  deep-seated  implantation,  early  symptoms 
may  be  entirely  wanting,  except,  perhaps,  polyuria,  which  may  not 
attract  attention,  or  else  may  be  erroneously  ascribed  to  some  other 
cause.  After  the  disease  has  existed  for  some  time  there  may  be  com- 
plaint of  pain  and  dragging  in  the   loin ;    and   bimanual   palpation  will 


TUBERCULOSIS   OF  THE    GENITO- URINARY  ORGANS.  267 

sometimes  discover  a  kidney-tumor,  which  may  often  be  made  out  to 
be  nodular  or  irregular  in  outline. 

In  some  cases,  the  tuberculous  granulation-process  may  cause 
thickening  or  swelling  of  the  mucosa  and  submucosa  of  the  pelvis  of 
the  kidney  and  ureter,  and  so  give  rise  to  swelling  and  enlargement  of 
the  organ.  In  other  cases,  and  more  particularly  after  considerable 
periods  have  elapsed,  the  pelvis  of  the  kidney  may  become  distended, 
and  the  ureter  also,  and  symptoms  of  hydro-  or  pyonephrosis  may 
result.  In  the  cases  of  implication  of  the  pelvis  of  the  kidney,  exam- 
ination of  the  urinary  sediments  may  serve  to  indicate  the  character  of 
the  process  ;  and  often  in  the  parenchymatous  form,  when  the  disease 
has  proceeded  to  caseation  and  ulceration,  the  detritus,  of  course,  gives 
evidence  of  its  tuberculous  character. 

Treatment. — In  cases  where  a  tumor  can  be  detected  in  the  loin, 
lumbar  incision  affords  at  once  a  means  of  diagnosis  and  one  of  the 
best  methods  of  treatment ;  for  then  drainage  can  be  established  and 
local  medication  carried  out.  In  case  of  extensive  disease  of  one  kid- 
ney only,  with  reasonable  assurance  of  the  integrity  of  the  other, 
nephrectomy  may  very  well  be  practised,  and  this,  oftentimes,  without 
a  preliminary  nephrotomy  and  drainage.  For  although  tubercle  here, 
as  elsewhere,  gives  rise  to  ulcerative,  destructive  effects  in  the  course 
of  its  development  within  an  organ,  without  interfering  with  the  utility 
of  surrounding  portions,  yet,  if  one  kidney  be  extensively  disorgan- 
ized, experience  has  shown  that  the  operation  of  nephrotomy  may  be 
attended  with  as  heavy  a  mortality  as  that  of  nephrectomy.  Careful 
observation  of  the  urine  and  catheterization  of  the  ureters  will  gener- 
ally enable  one  to  discover  the  relative  condition  of  the  two  kidneys. 
Therefore,  the  anterior  incision  need  no  longer  be  practised  with  a  view 
of  determining  the  condition  of  the  supposedly  unaffected  kidney. 

General  roborant  treatment,  with  the  employment  of  antiseptic  rem- 
edies voided  by  way  of  the  kidneys,  will  oftentimes  delay  the  progress 
of  the  disease  to  a  very  considerable  extent.  Even  if  both  kidneys  be 
partially  diseased,  it  is  still  possible  to  effect  some  good  surgically  by 
the  ablation  of  the  diseased  parts,  followed  by  suture. 

Nephrotomy  with  curettage,  followed  by  drainage  by  rubber  tubing 
and  iodoform  gauze,  after  irrigation  with  iodoform-glycerin  emulsion, 
has  afforded  the  writer  very  gratifying  results,  and  he  has  found  the 
subsequent  injection  of  iodoform  emulsion  (10  per  cent.)  combined 
with  a  weak  solution  of  chlorid  of  zinc  and  formaldehyd  to  distinctly 
diminish  the  amount  of  discharge  and  promote  cicatrization. 

If  there  is  a  condition  of  pyonephrosis  with  severe  general  symp- 
toms, or  if  there  is  a  complicating  perinephritic  abscess,  primary 
nephrectomy  should  not  be  attempted.  The  mortality  is  very  large 
under  these  circumstances,  and  it  is  safer  to  do  a  preliminary  nephrot- 
omy which  shall  be  followed  later  by  a  secondary  nephrectomy.  The 
drainage  afforded  by  the  incision  allows  the  acute  inflammatory  condi- 
tion to  subside,  and  the  patient  meanwhile  recuperates.  This  method 
of  treatment  will  be  followed  by  excellent  results. 

Nephrotomy  to  provide  an  exit  for  sloughs  is  a  proper  precaution- 
ary measure  before  using  the  tuberculin  treatment  in  nephrophthisis. 


268  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

In  doing  nephrectomy  for  tuberculous  kidney,  it  is  sometimes  neces- 
sary or  advisable  to  do  a  partial  or  complete  ureterectomy. 

The  great  danger  in  leaving  a  tuberculous  ureter  in  the  body  is  that 
it  may  cause  further  local  manifestations  of  the  disease,  either  imme- 
diately or  remotely.  Tubercular  abscesses  may  develop  in  the  loin  as 
late  as  two  years  after  a  nephrectomy  in  such  cases,  the  patient  in  the 
mean  time  being  in  good  health.  Another  danger  is  that  the  diseased 
ureter  may  serve  as  an  infecting  focus  for  the  dissemination  of  the  dis- 
ease in  other  parts  of  the  body.  The  removal  of  the  ureter  through 
an  extraperitoneal  incision,  if  quickly  performed,  does  not  add  much 
to  the  risk  of  the  operation. 


CHAPTER   XI. 
THE  TECHNIC  OF  ASEPTIC  SURGERY. 

The  middle-aged  surgeon  of  the  present  day  has  witnessed  the  be- 
ginning and  the  end  of  a  revolution  in  his  art,  which  represents  a  greater 
progress  than  has  been  made  in  all  the  preceding  centuries.  He  is 
fortunate  who,  with  personal  knowledge  of  the  black  septic  era,  is  still 
alive  to  enjoy  to  the  full  the  practice  of  surgery  under  the  reign  of 
asepsis. 

A  heavy  responsibility  rests  upon  the  younger  student  that  no  back- 
ward step  be  taken.  Let  him  carefully  study  the  history  of  surgery 
before  the  days  of  Joseph  Lister,  that  he  may  thoroughly  appreciate 
the  blessings  which  he  now  enjoys,  and  the  dangers  against  which  he 
must  be  ever  vigilant. 

The  surgeon  should  appreciate  the  fact  that  the  introduction  of  bac- 
teria into  the  body  takes  place  in  nearly  all  cases  through  some  lesion 
on  the  external  surface  of  the  body  or  in  a  mucous  tract,  and  that 
without  such  a  wound  bacterial  invasion  is  rare ;  that  the  commonest 
source  of  wound-infection  is  the  pyogenic  organism,  although  a  num- 
ber of  these  bacteria  are  required  to  cause  real  disturbance  of  wound- 
healing  ;  and,  finally,  that  the  success  of  this  invasion  is  dependent  not 
only  on  the  virulence  of  the  germ,  but  also  upon  the  condition  of  the 
soil,  the  tissues  and  fluids  of  the  individual,  and  upon  what  is  termed 
the  power  of  resistance  belonging  to  the  individual.  For  instance, 
linear  incisions  are  not  as  apt  to  be  the  seat  of  infection  as  contused 
and  lacerated  wounds.  Persons  weakened  by  disease  or  worn  out  by 
excessive  labor  yield  more  readily  to  infection  than  healthy  individuals. 
Some  individuals  possess  a  greater  power  of  resisting  the  effects  of 
germ-infection  than  others. 

It  is  now  established  that  nearly  all  bacterial  infection  can  be  traced 
to  man's  tangible  surroundings,  on  which  lies  dirt  of  various  kinds. 
The  dust  and  dirt  of  the  street  are  loaded  with  germ-life  of  all  kinds, 
moulds,  yeasts,  fungi,  bacilli,  cocci,  color-  and  odor-producing  bacteria 
being  present  in  countless  numbers.  This  vast  army  of  bacterial 
growth  is  readily  carried  by  currents  of  air  into  every  nook  and  corner, 
and  portions  of  it  are  liable  at  any  time  to  be  deposited  upon  every 
exposed  object,  including  the  clothes  and  body  of  every  individual.  It 
is  no  wonder,  then,  that  the  surface  of  the  body  should  be  a  nidus  for 
germs  of  all  kinds,  for  it  is  constantly  coming  in  contact  with  dust  and 
dirt  filled  with  germ-life.  Here  bacteria,  finding  suitable  conditions  for 
development — warmth,  moisture,  and  nutrient  media — propagate  with 
great  rapidity,  and  eagerly  enter  the  body  through  abrasions  of  the 
skin.  Careful  surgeons  therefore  use  every  means  at  their  command 
to  destroy  or  avoid  bacteria. 

269 


270  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

For  a  description  of  the  pyogenic  bacteria  the  reader  is  referred  to 
the  chapter  on  Surgical  Bacteriology. 

The  word  "  sepsis"  from  the  Greek  verb  avJTisiu,  was  formerly  used 
to  define  a  condition  known  as  putrefaction,  the  etiology  of  which  had 
not  been  discovered.  Gradually  this  term  came  to  be  employed  to 
denote  the  condition  found  in  pus-producing  wounds,  so  that  now  by 
sepsis  is  meant  the  condition  resulting  from  the  introduction  of  pyogenic 
bacteria  into  wounds.     All  sepsis  is  due  to  bacterial  invasion. 

By  the  term  "  antisepsis  "  is  meant  the  adoption  of  various  methods 
of  destroying  bacteria  or  inhibiting  them  in  their  growth.  Drugs  and 
methods  used  to  accomplish  this  result  are  termed  antiseptics.  True 
germicides  are  properly  called  antiseptics,  for  they  actually  kill  bacteria. 
Antiseptics  frequently  only  arrest  bacterial  development. 

Asepsis  means  absence  of  germs  which  produce  sepsis.  Ideal  asep- 
sis is  scarcely  possible,  for  it  must  be  conceded  that  even  perfect 
wounds  contain  bacteria,  which  are  either  non-virulent  or  too  few  in 
number  to  cause  trouble. 

It  is  now  generally  believed  that  air  is  comparatively  harmless  to 
wounds,  provided  that  it  is  moderately  free  from  dust.  Of  course,  the 
writer  does  not  claim  that  ordinary  air  is  in  any  strict  sense  aseptic,  but 
only  that  the  exposure  of  an  operative  wound,  during  the  short  period 
of  its  formation,  to  the  atmosphere,  is  not  followed  by  wound-disease. 
This  is  demonstrated  clinically  by  our  experience,  for  we  frequently 
obtain  long  series  of  wound-healings  unbroken  by  the  slightest  evi- 
dence of  infection,  although  we  make  no  special  provision  against  the 
free  admission  of  ordinary  air  to  the  freshly-made  wound.  Undoubt- 
edly some  bacteria  are  deposited  in  the  form  of  dust  upon  every  wound, 
but  ordinarily  not  in  sufficient  quantity  to  result  in  wound-disturbance. 
Sea  breezes  have  been  shown  to  be  free  from  bacteria,  whereas  land 
breezes  are  not  so.  City  air  is  more  contaminated  than  country  air. 
The  atmosphere  of  high  mountains  is  comparatively  free  from  germs, 
and  the  air  in  wet  weather  is  more  nearly  aseptic  than  when  it  is  dry ; 
these  facts  proving  that  bacteria  are  especially  abundant  in  the  air  in 
places  which  are  either  thickly  populated  or  where  dust  is  scattered 
abundantly  by  high  winds.  Gases  also  of  all  sorts  are  free  from  germs 
excepting  when  mixed  with  dust  or  spray,  and  the  prevalent  idea  that 
sewer  gas  may  cause  germ-infection  of  any  sort  is  incorrect.  That 
water  is  a  source  of  bacterial  infection  is  generally  known,  bacteria 
having  a  tendency  to  cling  to  water,  passing  from  it  into  the  air  only  in 
the  form  of  spray.  Ordinary  cold  water  is  laden  with  germs  and  fungi, 
therefore  it  must  not  be  brought  in  contact  with  aseptic  wound  sur- 
faces. Water  from  ordinary  hot-water  boilers,  on  the  other  hand,  is 
comparatively  germ-free,  and  can  be  used  with  safety  when  freshly 
boiled  water  cannot  be  obtained. 

It  is  the  aim  of  the  modern  surgeon  to  make  and  treat  wounds 
aseptically,  to  do  which  intelligently  implies  a  thorough  knowledge  of 
the  causes  of  infection  and  demands  at  least  an  elementary  study  of 
bacteriology.  Fortunately,  with  the  various  methods  of  sterilization 
at  our  command,  it  is  possible  to  render  all  operating  paraphernalia 
free  from  bacteria,  and  skin-sterilization,  although  not  perfect,  has  been 
of  late  years  enormously  improved. 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  2~I 

Successful  aseptic  surgery  depends  absolutely  upon  the  most  pains- 
taking attention  to  preliminary  details.  Not  only  must  each  individual 
item  in  the  surgeon's  armamentarium  be  germ-free,  but  also  every 
individual  employed  in  an  operation  must  realize  that  complete  failure 
may  follow  the  slightest  neglect  on  his  part.  The  duties  of  each 
should  be  appointed  before  the  operation  begins,  so  that  speed  may 
be  attained  without  confusion,  thus  avoiding  loopholes  for  errors  in 
technic.  After  the  sterilization  of  hands,  objects  which  have  not  been 
disinfected  must  not  be  touched.  Since  the  hands  are  the  most  frequent 
source  of  wound-infection,  as  few  as  possible  should  come  in  contact 
with  the  wound-surface.  The  dangers  of  infection  are  increased  by 
improper  hemostasis,  accumulation  of  serum  and  blood-clot  in  dead 
spaces,  the  presence  of  detached  or  poorly  nourished  particles  of  tissue, 
improper  drainage,  traumatism  by  rough  handling  of  tissues,  irregular 
incisions,  and  irrigation  of  wounds  with  caustic  solutions  which  produce 
superficial  necrosis,  thus  interfering  with  wound-repair.  Every  surgeon 
should  entertain  the  absolute  conviction  that  strict  attention  to  perfect 
aseptic  technic  will  accomplish  nearly  unfailing  success. 

The  making  of  wounds  with  instruments  and  hands  absolutely  free 
from  germ-life — that  is,  thoroughly  sterilized,  and  the  complete  avoid- 
ance of  allowing  any  object  not  completely  sterilized  to  come  in  con- 
tact with  the  wound-surface,  represents  what  we  mean  by  aseptic 
surgery.  Disinfectants  and  antiseptics  of  various  kinds  are  therefore 
used,  in  order  that  we  may  so  prepare  our  various  instruments  and 
surgical  materials  that  we  may  work  aseptically ;  and  it  has  been  clearly 
demonstrated  that  if  such  preparations  are  properly  made  before  an 
operation  is  begun,  and  if  no  fault  is  committed  by  the  operator  or 
his  assistants  during  the  course  of  an  operation,  the  wound  may  be 
made  and  treated,  until  healing  has  occurred,  without  the  use  at  any 
moment  after  the  beginning  of  the  operation  of  antiseptic  of  any 
kind. 

Ideal  asepsis  would  mean,  of  course,  that  not  even  one  bacterium  of 
any  variety  should  find  lodgement  in  the  wound.  Ideal  asepsis,  as  thus 
defined,  has  certainly  not  yet  been  attained,  but  fortunately  nearly  uni- 
form success  can  be  accomplished,  in  spite  of  the  entrance  into  wounds 
of  some  germ-life,  such  as  undoubtedly  is  deposited  from  ordinary  air 
upon  every  wound-surface.  To  diminish  the  number  of  these  acci- 
dental visitors  is  the  special  aim  of  the  aseptic  working  surgeon. 

Methods  of  Sterilization. — It  is  of  the  first  importance,  then,  to 
study  carefully  the  means  by  which  we  may  so  prepare  our  hands,  our 
instruments,  and  other  materials,  as  to  render  them  as  nearly  aseptic  as 
possible.  We  must  begin  with  the  methods  of  sterilization.  These 
methods  have  been  well  classified  by  Schimmelbusch  as  follows  : 
i.   Mechanical  cleansing. 

2.  Germicidal  agents,  chemical  and  thermal,  which  destroy  bacteria. 

3.  Agents  which  arrest  bacterial  development  and  prevent  ger- 

mination and  multiplication. 

4.  Antitoxin  agents  directed  not  against  microbes  themselves,  but 

against  ptomain-products. 

5.  Agents  not  affecting  bacteria  or  ptomaines,  but  increasing  the 

power  of  resistance  on  the  part  of  the  patient's  tissues. 


272  INTERNATIONAL    TEXT  BOOK   OF  SURGERY. 

This  classification  therefore  includes  the  use  of: 

I.  Mechanical  washing  and  scrubbing,  etc. 

f     Ti/r  -  .      f      Boiling  water. 
Moist    •       c.        s 

2    Heat  ^     Steam- 

-   Heat     I      n  f      Hot  air. 

[     Dry        1     Flame. 

3.  Chemicals. 

4.  Antitoxins,  etc. 

5.  The  attenuation  of  bacteria  by  multiple  infection. 

In  selecting  from  the  various  methods  of  disinfection  which  ones  he 
shall  use,  the  surgeon  must  be  governed  entirely  by  the  conditions 
under  which  he  is  placed.  Steam  cannot  be  used  for  the  disinfection 
of  hands,  therefore  other  methods  must  be  substituted.  Again,  other 
conditions  arise,  such  as  the  resistance  of  the  infectious  organisms  to 
be  destroyed  and  the  disinfecting  power  of  the  agents  to  be  employed, 
the  resistance  offered  by  the  form  and  shape  of  the  object,  the  thickness 
and  kind  of  dirt,  the  chemical  changes  that  may  occur,  the  element  of 
time,  and  the  expense  of  the  disinfectant. 

Mechanical  Cleansing. — While  the  methods  of  sterilization  are 
numerous,  by  far  the  most  useful  and  most  important  is  mechanical 
cleansing,  not  only  as  applied  to  the  patient,  but  also  to  the  immediate 
surroundings.  Whatever  success  was  obtained  before  the  discovery  of 
antisepsis  was  due  in  a  great  measure  to  cleanliness  and  proper  hygienic 
surroundings.  The  removal  of  dirt  by  washing,  scrubbing,  and  shav- 
ing not  only  disposes  of  enormous  masses  of  bacteria,  but  so  prepares 
the  various  surfaces  that  other  methods  of  sterilization  can  be  success- 
fully used  in  attacking  such  germs  as  remain. 

Heat. — As  a  general  disinfectant  no  agent  is  so  valuable  as  heat,  and 
only  when  it  cannot  be  applied  in  one  form  or  another  should  chemical 
sterilization  be  made  use  of.  Heat  may  be  applied  either  in  the  form  of 
the  flame  or  of  boiling  water.  The  actual  cautery  may  be  used  for 
sterilizing  septic  surfaces,  the  flame  for  the  sterilization  of  instruments  ; 
but  its  use  for  this  purpose  is  generally  to  be  condemned,  as  it  discolors 
and  injures  metal. 

The  anthrax  organism  is  one  of  the  most  resistant  pathological 
germs,  yet  it  is  destroyed  by  boiling  water  in  two  minutes.  Bacteria 
without  spores  have  yielded  to  this  agent  in  from  one  to  five  seconds, 
and  the  most  resistant  bacteria  in  from  fifteen  to  thirty  minutes ;  there- 
fore the  practical  utility  of  boiling  water  is  evident,  for  it  is  not  only  very 
efficient  but  inexpensive,  constantly  at  hand,  and  requires  little  time  in 
preparation.  Its  use,  however,  is  limited  to  the  preparation  of  solutions, 
suture-materials,  instruments,  and  dressings. 

Steam. — As  a  sterilizing  agent,  steam  possesses  a  higher  value  than 
hot  air,  as  it  requires  a  shorter  time  and  is  more  thorough.  The  tem- 
perature necessary  is  lower,  and  it  does  not  burn  dressings  and  cloth- 
ing, nor  render  them  fragile  or  useless.  Live  steam  will  kill  anthrax 
spores  in  from  five  to  fifteen  minutes.  Hot  air  takes  much  longer  to 
accomplish  the  same  object.  Steam  may  be  used  in  the  following  forms 
for  disinfecting  purposes  :  a.  Quiescent — simple  steam  ;  /;.  Circulating 
freely — live  steam ;  c.  Under  pressure — high-tension  steam ;  d.  If 
raised  by  flame  at   ioo°  C. — superheated  steam. 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  273 

Of  these  various  forms,  live  steam  has  proved  to  be  more  germi- 
cidal than  simple  steam,  and  that  known  as  high  tension  is  the  most 
potent  of  all.  Various  appliances  called  steam  sterilizers  are  found  in 
the  market.  One  should  be  familiar  with  the  requisites  of  a  proper 
sterilizer,  and  a  brief  description  of  those  generally  believed  to  be  most 
suitable  for  hospital  and  private  work  is  here  given.  The  requisites  for 
the  best  sterilizer  may  be  summed  up  as  follows:  1.  Proper  shape — 
prevention  of  dead  spaces  ;  2.  Saturated  steam  ;  3.  Prevention  of  con- 
densation ;  4.  Pressure;  5.  An  equable  temperature;  6.  Devices  for 
drying  dressings  ;  7.  Cheapness  and  ease  of  manipulation. 

Whether  the  sterilizer  be  large  or  small,  it  is  advantageous  to  avoid  square  corners,  for  in 
these  air  is  apt  to  collect,  and  steam  does  not  penetrate  satisfactorily,  so  that  portions  of 
materials  occupying  such  spaces  are  not  sterilized  properly. 

The  length  of  the  sterilizer  must  also  be  limited,  for  the  longer  it  is,  the  greater  is  the 
difficulty  of  maintaining  an  equable  temperature.  Steam  filling  such  a  reservoir  should  be 
saturated — that  is,  there  should  be  no  admixture  of  gas.  This  can  be  accomplished  in  either 
of  two  ways — by  creating  a  vacuum  before  admitting  the  steam,  or  by  admitting  steam  from 
above.  The  vacuum  drives  the  air  not  only  from  the  chamber,  but  also  from  the  objects 
enclosed,  and  thus  indirectly  helps  to  heat  these,  both  by  preventing  condensation  and  also 
by  aiding  future  penetration  by  raising  the  pressure  of  steam  forced  in  later.  Thus,  with  a 
preliminary  vacuum,  steam  at  ten  pounds'  pressure  is  as  good  as  steam  at  twenty  pounds  with- 
out a  vacuum.  For  all  practical  purposes,  however,  the  admission  of  steam  from  above  will 
drive  the  air  out  sufficiently  well.  Special  emphasis  is  laid  upon  the  admission  of  steam  from 
above,  because  in  this  way  air  will  be  forced  out  steadily  and  uniformly,  steam  being  lighter 
than  air  ;  whereas,  if  it  comes  from  below,  the  steam  passes  up  in  eddies  and  escapes  in  part, 
without  forcing  the  air  out  completely.  As  the  live  steam  passes  into  the  sterilizer,  there  is 
a  tendency  for  it  to  give  up  its  latent  heat,  not  only  to  the  walls  of  the  chamber,  but  also  to 
the  dressings  enclosed.  The  result  is  condensation  and  a  formation  of  drops  of  water,  which 
line  the  wall  of  the  sterilizer  and  wet  the  dressings.  To  exclude  this  defect  absolutely  is 
very  difficult,  but  certain  methods  are  made  use  of,  which  render  damage  from  this  source  an 
infrequent  occurrence.  In  the  first  place,  all  sterilizers  should  be  surrounded  with  a  steam 
jacket,  through  which  steam  hotter  than  that  in  the  chamber  should  pass,  and  the  element  of 
condensation  will  thus  be  avoided.  This  jacket  has  the  advantage  not  only  of  preventing 
condensation,  but,  as  it  becomes  superheated,  the  steam  is  kept  in  circulation  by  the  effect 
of  this  increased  temperature  on  the  sides  of  the  jacket.  Objects  before  being  brought  in 
contact  with  steam  should  be  thoroughly  heated,  so  that  when  they  are  exposed  to  the  vapor, 
condensation  will  not  be  as  likely  to  occur.  Preparatory  warming  does  not  entirely  prevent 
condensation,  because  the  hot  air  does  not,  as  a  rule,  penetrate  to  the  center  of  the  objects 
to  be  sterilized,  and  the  cold  air  in  the  center  may  cause  some  condensation.  With  a  steam 
jacket,  however,  the  steam  in  the  chamber  is  inclined  to  be  superheated,  and  the  extra  heat 
is  sufficient  to  cause  re-evaporation  of  moisture,  so  that  objects  eventually  come  out  dry  and 
little  harmed.  It  has  been  conclusively  shown  that,  in  order  to  get  the  greatest  benefit  from 
steam  sterilization,  the  live  steam  should  be  kept  under  pressure.  High-pressure  steam,  and 
by  this  is  meant  steam  under  pressure  of  from  ten  to  fifteen  pounds  to  the  square  inch  at 
2400  F.,  has  the  advantage  over  steam  at  low  pressure  that  it  is  more  penetrating  and  more 
germicidal.  It  is  also  less  liable  to  condensation  and  can  be  easily  obtained  from  any  neigh- 
boring steam-pipes,  so  that  special  apparatus  for  its  manufacture  is  not  required.  Its  disad- 
vantages are  increased  care  and  expense  in  the  manufacture  of  sterilizers,  and  more  care 
required  in  handling  them.  The  best  penetration  can  be  obtained  by  relaxing  the  pressure 
during  sterilization  and  refilling  the  chamber  with  steam  several  times,  thus  driving  out  the 
air  in  the  materials  to  be  disinfected.  The  maintenance  of  an  equable  temperature  through- 
out the  process  of  sterilization  in  every  corner  of  the  sterilizer  is  very  necessary  ;  otherwise, 
disinfection  will  not  be  complete,  and  it  is  only  by  keeping  high,  steady  pressure,  by  pre- 
venting condensation,  and  by  obtaining  a  complete  liberation  of  air  from  the  chamber,  that 
such  a  temperature  can  be  procured.  Should  the  dressings  be  found  moist  after  being  steril- 
ized, an  easy  method  of  drying  consists  in  turning  off  the  steam  in  the  chamber  and  con- 
tinuing that  in  the  steam  jacket.      Dressings  may  then  be  readily  dried. 

The  following  articles  may  be  exposed  to  steam  for  sterilization : 
Dressings,  towels,  gowns,  suture-material  of  some  sorts,  solutions  in 
glass  jars,  gauze  impregnated  with  chemicals,  such  as  iodoform  and 
balsam  of  Peru,  and  infected  clothing.     Rubber  and  leather  cannot  be 

is 


274 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


sterilized  by  steam  without  injury.  Before  exposing  articles  to  steam 
sterilization  care  must  be  taken  not  to  pack  them  too  tightly  together 
— that  is,  air  spaces  should  exist  between  the  different  objects.  Articles 
should  not  come  in  contact  with  the  sides  of  the  sterilizer;  otherwise, 
drops  of  moisture  which  accumulate  upon  the  lining  may  fall  upon 
them.  All  materials  should  be  heated  before  they  are  exposed  to 
steam.     The  time  required  for  steam  sterilization  is  dependent  upon 

several    different     conditions, 
flj  as,  for  instance,  the   amount 

of  pressure,  the  temperature, 
the  compactness  of  the  arti- 
cles to  be  disinfected,  and  the 
nature  and  virulence  of  the 
organism  to  be  destroyed. 
As  a  rule,  to  secure  a  per- 
fect germicidal  action,  articles 
must  be  exposed  for  fifteen 
minutes  under  ten  pounds' 
pressure  and  a  heat  of  2400 
F.  for  three  consecutive  peri- 
ods twenty-four  hours  apart, 
in  order  to  allow  for  the  de- 
velopment of  spores,  which 
are  more  resistant  than  the 
germs  themselves.  For  or- 
dinary purposes,  the  common 
vegetative  germ  may  be  killed 
if  sterilization  is  continued  for 
three-quarters  of  an  hour  on 
one  occasion. 

For  hospital  work  the  Kny-Sprague 
Sterilizer  (  Fig.  56)  has  proved  to  be  as 
useful  as  any.  It  consists  of  a  cylin- 
drical chamber,  surrounded  by  a  steam 
jacket,  attached  to  which  is  an  arrange- 
ment for  creating  a  vacuum  when  re- 
quired. The  water  is  heated  from 
beneath  by  gas,  or  by  steam  collected 
through  pipes  from  some  neighboring 
boiler.  The  steam  jacket,  half-filled 
with  water,  generates  the  requisite 
amount  of  steam,  under  pressure  of 
from  ten  to  twenty  pounds,  at  a  tem- 
perature of  from  2300  to  2600  F.  ; 
then  the  air  in  the  sterilizing  chamber 
is  exhausted  by  the  vacuum  apparatus, 
and  the  steam  turned  in.  The  steam 
is  allowed  to  circulate  freely  for  from 
fifteen  to  thirty  minutes,  according  to 
the  density  of  the  objects  exposed, 
and  is  then  turned  off.  The  residual  steam  is  now  removed  by  creating  a  vacuum,  and  the 
materials  are  then  dried  by  the  heat  generated  in  the  jacket  surrounding  the  chamber. 
This  will  require  from  ten  to  twenty  minutes.  By  turning  a  valve,  filtered  air  is  allowed 
to  pass  into  the  chamber,  thus  relieving  the  vacuum,  and  the  materials  are  removed  dry  and 
sterile.  Smaller  sterilizers  for  private  work  are  made  of  the  same  pattern,  which  answer 
the  purpose  admirably.  Where  a  condensation  instrument  and  steam  sterilizer  without  press- 
ure are  desired,  the  Schimmelbusch  apparatus  is  found  to  be   very  efficient.      In  this  the 


FIG.  56. — Kny-Sprague  sterilizer:  a,  funnel  and 
valve  where  water  is  taken  into  the  jacket;  b,  valve 
for  discharge  of  air  displaced  by  the  water ;  c,  gas 
attachment ;  d,  safety  valve  ;  e,  valve  which  controls 
the  steam  for  vacuum  apparatus  ;  f,  valve  admitting 
steam  from  jacket  to  chamber  ;  g,  glass  water-gauge  ; 
h,  ventilating  pipe  for  gas  combustion  ;  /',  test-valve 
for  steam  in  chamber;  k,  air-filtering  valve  for  de- 
stroying vacuum. 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  2J$ 

steam  escaping  from  the  water  used  for  boiling  instruments  sterilizes  the  dressings.  The 
dressings  are  ranged  in  packs  constructed  after  the  manner  described  in  the  chapter  on 
Dressings,  and  are  then  placed  above  the  apartment  used  for  the  sterilization  of  instruments. 
Hot-air  sterilizers  have  proved  to  be  of  no  practical  value  in  surgery,  and  therefore  need  not 
be  here  described. 

Chemical  Disinfection. — Chemical  disinfection,  although  inferior  to 
mechanical  and  thermal  methods,  nevertheless  must  be  employed  under 
certain  conditions.  Chemical  antiseptics  are  now  generally  used  simply 
for  the  purpose  of  obtaining  an  aseptic  condition  prior  to  operation.  A 
chemical,  in  order  to  be  an  ideal  disinfectant,  must  have  certain  proper- 
ties. It  must  be — I.  Soluble  and  penetrating;  2.  Actively  germicidal ; 
3.  Effective  in  a  brief  time ;  4.  Non-poisonous;  5.  Neither  destructive 
to  materials  nor  irritating  to  wound-surfaces  ;  6.  Not  decomposable, 
and  not  rendered  inert  by  condensation  ;  7.  Inoffensive  in  odor ;  8.  In- 
expensive. 

No  chemical  combining  all  these  valuable  qualities  has  yet  been 
discovered.  Only  a  few  chemicals  have  germicidal  action  on  anthrax 
spores,  even  when  the  latter  have  been  exposed  to  them  for  twenty-four 
hours.  These  are — bichlorid  of  mercury,  iodin,  chlorin,  bromin,  tri- 
chlorid  of  iodin,  and  creosote   mixed  with  sulphuric  acid. 

A  few  are  germicidal  after  continuous  contact  for  a  number  of  days. 
Such  are — carbolic-acid  solution,  5  to  100;  ligneous  vinegar ;  chlorid- 
of-lime  solution,  5  to  100 ;  turpentine  ;  formic  acid;  chlorid-of-iron  so- 
lution, 5  to  100;  quinin;  muriate  solution,  1  to  100;  arsenious-acid 
solution,  1  to  1000;  muriatic-acid  mixture,  2  to  100;  sulphuric  ether. 

The  vegetative  forms  of  bacteria  are  not  so  resistant,  and  will  suc- 
cumb even  to  some  of  the  weaker  chemicals ;  but  still  the  antiseptic 
power  of  these  drugs  is  far  below  that  of  heat,  for  it  has  been  found 
that  the  Staphylococcus  pyogenes  aureus  is  not  completely  destroyed 
when  subjected  for  fifteen  minutes  to  the  action  of  a  1  to  1000  bichlorid- 
of-mercury  solution. 

In  regard  to  the  value  of  chemicals  for  disinfection,  laboratory  ex- 
perience sometimes  produces  different  results  from  those  obtained  in 
surgical  work,  because  the  conditions  are  different.  For  instance,  in 
laboratory  experimentation  a  few  germs  are  exposed  to  a  large  quan- 
tity of  the  chemical ;  but  in  surgical  work  the  reverse  holds  true,  for  in 
the  latter  case  sterilization  is  attempted  upon  masses  of  bacteria  hidden 
away,  often  in  impermeable  matter,  such  as  coatings  of  fat,  so  that  very 
little  antiseptic  ever  reaches  many  of  the  germs.  Then,  too,  most  anti- 
septics on  coming  in  contact  with  wound-discharges  break  up  into 
combinations  which  are  inert,  uniting  more  commonly  with  the  albumin 
contained  in  wound-discharges.  While  comparatively  few  different 
chemical  antiseptics  are  at  present  made  use  of,  the  more  important 
ones  that  have  been  recommended  of  late  years  will  be  now  enumer- 
ated: 

Chemicals  for  disinfection  are  used  either  as  powders  or  in  solutions 
of  a  watery  or  oily  character,  and  they  are  here  classified  according  to 
their  germicidal  power : 

Bichlorid  of  mercury  is  the  most  active  of  all.  It  occurs  as  a  white,  crys- 
talline, odorless  powder,  very  poisonous,  and  soluble  to  saturation  in  1  to 
16  of  cold  water,  1  to  3  of  alcohol,  and  is  also  freely  soluble  in  ether  and 


276  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

volatile  oils.  It  promptly  decomposes  on  touching  metals,  and  there- 
fore cannot  be  used  for  sterilizing  instruments,  nor  should  it  come  in 
contact  with  metallic  apparatus  of  any  sort.  Mixed  with  ordinary 
water,  it  has  been  found  that  earthy  substances,  carbonic  alkalies,  com- 
bine with  the  salt,  causing  an  inert  precipitate.  This  is  to  be  avoided 
by  using  hot  distilled  water  and  adding  equal  parts  of  salt  and  one  of 
the  following  substances :  Sodium  chlorid,  tartaric  acid,  hydrochloric 
acid,  or  salicylic  acid,  to  a  given  quantity  of  water.  The  solution,  even 
with  distilled  water,  soon  becomes  inert  on  standing,  on  account  of  the 
formation  of  an  oxychlorid.  Light  also,  after  a  short  time,  causes  a 
partial  decomposition,  precipitating  calomel,  and  forming  hydrochloric 
acid.  A  1  to  1000  solution  is  used  in  the  disinfection  of  skin-surfaces. 
For  this  purpose  it  can  be  actively  useful  only  after  oily  material  has 
been  removed  from  the  area  to  be  disinfected.  In  sterilization  of  jars, 
bowls,  etc.,  before  operation,  corrosive  sublimate  is  valuable  in  the  same 
strength,  also  in  the  preservation  of  catgut  in  alcoholic  solution,  rubber 
tissue,  sponges,  and  tubing.  Bichlorid  of  mercury  should  not  be  used 
on  wound-surfaces  for  several  reasons:  In  the  first  place,  it  causes 
superficial  necrosis,  even  when  employed  in  the  strength  of  1  part  to 
10,000,  and  thus  favors  a  multiplication  of  micro-organisms,  and  when 
it  comes  in  contact  with  the  albumin  in  pus,  blood,  or  in  any  tissue, 
the  salt  decomposes,  forming  an  inert  salt  of  albuminate  of  mercury, 
which  simply  surrounds  each  spore  or  bacterium,  forming  a  capsule, 
and  thus  further  disinfection  is  prevented. 

Poisonous  symptoms  have  frequently  been  noted  as  a  result  of  the 
continued  use  of  this  drug.  Wheri  used  continually  by  the  surgeon, 
the  hands  become  blackened,  rough,  and  cracked,  and  in  that  condition 
are  especially  liable  to  harbor  bacteria.  Local  irritation,  resulting  in 
an  angry  dermatitis,  often  follows  the  application  of  moist  bichlorid 
dressings,  and  when  solutions  of  bichlorid  have  been  used  for  contin- 
uous irrigation,  symptoms  of  violent  gastro-enteritis,  colicky  pains,  vom- 
iting, and  salivation  sometimes  occur.  For  ease  of  transportation  cor- 
rosive-sublimate tablets  are  sold.  The  outer  coating  of  such  tablets 
after  a  time  changes  to  calomel,  and  thus  the  strength  of  the  tablet 
becomes  lessened.  A  10  per  cent,  solution  is  more  useful,  2  drams  of 
which,  added  to  a  quart  of  water,  cause  a  solution  of  the  strength  of  1 
part  to  1000  of  the  pure  salt.  About  j\  grains  added  to  the  pint  make 
a  solution  of  the  same  strength. 

Carbolic  acid,  Lister's  original  disinfectant,  is  a  local  caustic,  coagu- 
lating albumin,  and,  like  corrosive  sublimate,  should  not  be  used  on 
wound- surfaces,  on  account  of  its  irritating  effect.  It  is  not  nearly  as 
powerful  a  germicide  as  bichlorid  of  mercury,  requiring  from  fifteen  to 
twenty  minutes  for  the  destruction  of  vegetative  bacteria.  It  has  the 
advantage  of  permeating  oily  substances  and  of  retaining  its  stability. 
It  is  cheap,  a  good  deodorizer,  and  has  a  slight  anesthetic  effect  on 
tissues. 

When  the  hands  of  the  operator  come  in  contact  with  carbolic-acid 
solution  for  any  length  of  time,  they  become  very  tender,  rough,  and 
cracked.  Poisonous  effects  may  occur,  both  locally  and  constitution- 
ally. Continuous  use,  as  in  the  form  of  hot  poultices,  often  causes  an 
acute  inflammation  and  desquamation,  and  strong  solutions  may  pro- 


THE    TECHNIC   OF  ASEPTIC  SURGE R  V.  277 

duce  gangrene.  It  is  especially  poisonous  to  children.  When  the 
drug  is  applied  to  wound-surfaces  for  some  time,  sufficient  absorption 
may  take  place  to  cause  general  weakness,  sweating,  increased  sali- 
vation, anorexia,  nausea,  vomiting,  headache,  vertigo,  and  irregular 
breathing,  with  rapid  and  feeble  pulse.  If  the  absorption  of  carbolic 
acid  continues,  the  patient  passes  into  coma,  preceded  by  clonic 
spasms,  and  followed  by  collapse  and  death.  The  urine  soon  gives 
a  characteristic  appearance,  becoming  green,  then  brown  and  smoky, 
and  an  absence  of  the  normal  amount  of  sulphates  is  noted. 

Other  antiseptics  of  minor  importance  are  lysol,  creolin,  salicylic  acid,  boric  acid,  potas- 
sium permanganate,  oxalic  acid,  and  chlorin  water.  Of  these,  lysol,  creolin,  and  salicylic 
acid  have  many  of  the  characteristics  of  carbolic  acid,  but  no  special  advantages.  Potas- 
sium permanganate,  oxalic  acid,  and  chlorin  water  are  of  interest  chiefly  from  their  use  in 
some  of  the  chemical  processes  for  the  disinfection  of  the  hands.  Boric  acid  is  used  simply 
for  irrigation  of  mucous  membranes.      For  this  purpose  salt  solution  is  better. 

Hydrogen  peroxid  has  become  very  popular  in  the  treatment  of  sup- 
purating wounds.  It  is  a  clear  fluid,  the  full  strength  being  called  15 
volume  solution,  by  which  is  meant  that  15  volumes  of  oxygen  are 
contained  in  each  volume  of  the  liquid  in  very  feeble  combination. 
The  precise  value  of  this  drug  as  an  antiseptic  has  not  been  deter- 
mined. The  bacillus  of  tetanus  has  been  cultivated  in  a  full-strength 
solution.  It  is  supposed  to  act  upon  the  albuminoid  elements,  on 
which  the  bacillus  lives,  through  its  power  of  oxidation.  Strong  solu- 
tions are  non-poisonous,  but  if  it  is  used  continually  on  wound-sur- 
faces, the  latter  become  sluggish  and  pale,  and  the  tendency  to  heal 
seems  to  diminish.  As  a  cleansing  agent  and  deodorizer  for  foul-smell- 
ing and  suppurating  wound-surfaces  hydrogen  peroxid  is  very  valu- 
able, if  not  used  for  too  long  a  time,  such  wounds  becoming  healthy 
looking  and  inoffensive  as  the  discharges  are  oxidized.  When  hydro- 
gen peroxid  is  applied,  ebullition  occurs  until  the  drug  is  exhausted 
or  the  pus  has  oxidized.  It  should  not  be  used  on  fresh  aseptic  wound- 
surfaces.  For  irrigating  suppurating  cavities  hydrogen  peroxid  is  very 
efficacious.  It  should  be  kept  in  the  dark  and  cold.  Variability  of 
strength,  ready  decomposition,  and  expense  limit  the  use  of  this  agent. 
For  ordinary  purposes  the  strength  made  use  of  is  from  3  to  5  per 
cent. 

Sodium  chlorid,  or  common-salt  solution,  in  the  physiological 
strength  of  y6^  of  1  per  cent.,  rendered  sterile  by  heat,  is  mentioned 
last,  not  on  account  of  its  minor  importance,  but  because  it  is  only 
indirectly  antiseptic.  It  is  prepared  in  the  following  manner :  6  drams 
of  sodium  chlorid,  first  sterilized  by  heat,  are  added  to  1  liter  of  dis- 
tilled water,  which  is  contained  in  an  oval  glass  flask  that  has  also 
been  sterilized.  This  flask  should  not  be  entirely  filled,  in  order  to 
allow  for  expansion,  and  should  be  sealed  with  absorbent  cotton  and 
covered  with  a  handkerchief  of  gauze  fastened  tightly  to  the  neck  of 
the  flask,  so  as  to  keep  the  lips  of  the  bottle  sterile.  The  solution 
thus  made  should  be  exposed  to  steam  sterilization  for  one-half  hour 
on  two  successive  days. 

For  simple  mechanical  irrigation  salt  solution  is  of  the  greatest 
value,  especially  when  applied  to  mucous  membranes,  fresh  wounds, 
and  serous  surfaces,  and  inasmuch  as  it  is  mild  and  soothing,  non- 


2^8  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

poisonous,  and  easily  obtained,  is  by  far  the  best  irrigating  fluid  that 
can  be  employed.  It  is  the  only  chemical  preparation  that  does  not 
produce  irritation  when  brought  in  contact  with  wound-surfaces. 
After  its  use  aseptic  wounds  may  be  closed,  for  the  tissues  will  have 
suffered  no  more  injury  than  is  caused  by  the  ordinary  operative 
manipulation,  and  septic  tissues  already  weakened  by  bacterial  poisons 
will  be  much  more  capable  of  resisting  pathogenic  organisms  than  if 
exposed  to  caustic  applications. 

During  operations  salt  solution  is  used  for  clearing  away  blood- 
clots,  one  of  its  effects  being  to  cause  various  tissues  to  become  more 
clearly  defined,  so  that  the  surgeon  is  enabled  more  readily  to  distin- 
guish the  proper  landmarks.  Its  use  in  skin-grafting,  and  also  as  an 
intravenous  infusion,  is  well  known. 

Alcohol  is  a  preservative  agent  and  not  a  germicide,  although  it  pre- 
vents to  a  certain  degree  the  growth  of  bacteria  by  dehydrating  the  tis- 
sues. Its  use  in  surgery  is  limited  to  the  preservation  of  materials,  such 
as  catgut  which  has  been  previously  sterilized,  and  to  the  sterilization 
of  the  skin  through  its  power  of  removing  superficial  layers  of  fatty 
material  and  withdrawing  water  from  the  tissues. 

Ether  and  turpentine  are  used  principally  for  the  purpose  of  cleansing 
the  skin  by  removing  dirty  and  fatty  substances. 

Numerous  powders,  said  to  possess  more  or  less  value  as  antiseptics, 
have  been  recommended  from  time  to  time  to  the  profession.  Aseptic 
wounds  can  certainly  not  be  benefited  by  the  application  of  any  powder, 
and  much  better  applications  can  be  made  to  septic  surfaces.  No  pow- 
ders are  germicidal,  as,  in  their  original  form,  they  are  non-penetrating, 
and  bacteria  can  live  even  when  surrounded  by  the  most  powerful  so- 
called  antiseptic  powder,  if  it  is  dry.  When  applied  to  a  septic  surface, 
the  absorption  of  a  little  moisture  causes  the  formation  of  an  artificial 
scab,  and  so  prevents  the  escape  of  septic  secretions  from  the  wound- 
surface.  This  dry  covering  renders  the  next  cleansing  of  the  wound 
difficult,  and  its  mechanical  removal  produces  fresh  traumatism.  More- 
over, the  absorption  of  such  powders  is  only  limited  with  certainty  by 
the  amount  that  is  applied,  so  that  those  which  are  poisonous  in 
quality  are  capable  of  doing  serious  harm. 

Iodoform,  however,  deserves  especial  attention,  because  it  is  at  pres- 
ent in  very  general  use.  Many  surgeons  rarely  apply  it,  and  it  probably 
will  not  long  occupy  a  position  of  importance  in  aseptic  work.  Iodo- 
form is  a  light-yellow,  crystalline  substance,  of  peculiar  odor,  very 
poisonous,  soluble  in  alcohol,  ether,  chloroform,  and  in  some  oils  and 
fats.  It  is  not  soluble  in  water.  Iodoform  is  not  actively  germicidal, 
but  its  application  seems  to  render  the  wound-area  unsuitable  for  the 
propagation  of  the  bacteria  of  infection.  Perhaps  its  action  is  due  to 
the  decomposition  which  takes  place  when  it  comes  in  contact  with  the 
ptomains  and  leukomains  produced  by  bacteria.  Iodin  being  eliminated 
renders  the  wound  unfit  for  the  growth  of  bacteria.  Both  the  Strepto- 
coccus pyogenes  albus  and  the  Staphylococcus  pyogenes  albus  have 
been  often  found  to  flourish  in  iodoform  powder  when  it  is  not  in  con- 
tact with  living  tissues  ;  therefore,  before  its  use,  it  should  be  rendered 
sterile  by  a  soaking  in  1  to  1000  bichlorid-of-mercury  solution  for  at 
least  five  minutes.     Iodoform  is  applied  to  foul  septic  wounds  either  as 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  279 

a  powder  or  in  the  form  of  iodoform  gauze,  and  certain  mixtures  con- 
taining iodoform  are  made  use  of  for  injection  into  tubercular  and  other 
lesions.  Iodoform  in  any  form  should  not  be  applied  to  an  aseptic 
wound.  When  used  as  an  injection,  mixed  either  with  glycerin,  vaselin, 
or  ether,  the  preparation  should  always  be  carefully  sterilized.  The 
preparation  of  iodoform  gauze  is  described  with  other  dressings.  The 
disagreeable  odor  of  the  powder  can  be  mitigated  by  mixing  with 
it  burned  coffee  powder,  or  some  aromatic  oil.  On  account  of  its 
odor,  iodoform  has  been  supplanted  to  some  extent  by  drugs  of  the 
same  general  character,  but  with  a  less  disagreeable  smell,  of  which  the 
following  are  the  more  important :  Dermatol,  iodol,  aristol,  salol,  soz- 
iodol,  sulphaminol. 

Dermatol  and  aristol  are  the  best  of  these,  and  are  useful  sometimes 
for  application  to  simple  excoriated  surfaces. 

Iodoform  is  capable  of  producing  active  local  and  constitutional  poi- 
sonous effects.  Locally,  it  sometimes  gives  rise  to  a  violent  dermatitis, 
requiring  its  immediate  disuse. 

Schede  describes  the  constitutional  poisonous  effects  as  follows : 

1.  High  fever. 

2.  Fever  with  gastro-intestinal  irritation,  rapid  pulse,  and  depres- 

sion of  spirits. 

3.  Very  rapid  compressible  pulse  without  fever.     This  is  a  dan- 

gerous form. 

4.  Very  rapid  pulse  and  very  high  fever. 

5.  Great  depression,  collapse,  early  death. 

6.  Cerebral  symptoms  somewhat  resembling  those  indicating  men- 

ingitis. 

In  most  cases  suffering  from  iodoform  poisoning,  iodin  may  be  de- 
tected in  the  urine  by  adding  a  small  quantity  of  commercial  nitric  acid 
and  a  little  chloroform.  Upon  shaking  the  mixture,  the  chloroform 
will  acquire  a  purple  color,  due  to  the  free  iodin  which  is  liberated,  and 
will  settle  as  a  purple  layer  at  the  bottom  of  the  vessel. 

Other  powders,  such  as  boric  acid,  calomel,  europhen,  oxid  of  zinc, 
lycopodium,  subnitrate  and  subiodid  of  bismuth  and  naphthalin,  are 
occasionally  used,  but  have  no  real  value  in  the  treatment  of  wounds. 
Oils  and  ointments,  whether  they  contain  antiseptics  or  not,  should  be 
thoroughly  sterilized  before  use,  otherwise  they  furnish  an  excellent 
medium  for  the  growth  of  bacteria.  Fatty  materials,  in  general,  pro- 
tect bacteria  from  the  destructive  action  of  chemical  antiseptics.  They 
are  certainly  of  value  as  soothing  applications  to  some  inflamed  sur- 
faces, and  by  softening  render  the  removal  of  dry  scales  and  masses 
of  epithelium  more  easily  accomplished. 

Sterilisation  of  Water. — Water  may  be  rendered  free  from  germ- 
life  by  the  addition  of  chemicals,  such  as  carbolic  acid,  bichlorid  of 
mercury,  etc.,  but  for  application  to  wound-surfaces  the  chemicals  used 
in  sterilizing  water  are  undesirable.  Water  may  be  rendered  perfectly 
free  from  bacterial  life  by  boiling.  Even  when  boiled,  however,  dirty 
water,  although  in  this  manner  completely  sterilized,  contains  foreign 
material,  which  is  not  desirable  for  wounds.  Water  should  therefore, 
previous  to  its  final  preparation,  be  either  distilled  or  filtered.  It  may 
then  be  sterilized  by  boiling  for  half  an  hour  or  even  a  much  shorter 


280  INTERNATIONAL    TEXTBOOK  OF  SURGERY. 

time.  With  a  sterilized  dipper  it  may  then  be  transferred  to  properly 
prepared  pitchers  or  bowls.  When  handled  in  this  manner,  however, 
water  of  an  absolutely  perfect  quality  cannot  be  furnished ;  for  its  ex- 
posure to  the  air,  in  transferring  it  from  one  vessel  to  another,  and  the 
use  of  different  utensils  in  the  same  process,  necessarily  expose  it  to 
the  entrance  of  some  bacilli.  To  be  rendered  absolutely  sterile  and  to 
remain  in  that  condition  until  brought  to  the  operating  table,  water 
must  be  prepared  as  follows : 

Glass  flasks,  which  have  been  perfectly  cleansed,  are  to  be  filled  nearly  to  the  top  with 
pure  filtered  or  distilled  water.  The  flasks  are  to  be  plugged  with  cotton,  over  which  a 
piece  of  gauze  should  be  tied  to  prevent  displacement  of  the  cotton  and  contamination  of 
the  edge  of  the  flask-mouth.  The  flasks  are  then  to  be  subjected  to  steam-sterilization 
under  pressure,  exactly  as  dressings  are,  and  should  remain  in  the  sterilizer  for  at  least  one- 
half  hour.  This  process  should  be  repeated  two  days  in  succession,  in  order  that  spores 
which  may  have  survived  the  first  boiling  may  be  destroyed  by  the  second.  Water  prepared 
in  this  manner  may  be  kept  unchanged  for  an  indefinite  length  of  time,  if  the  plug  of  cotton 
is  not  removed  from  the  mouth  of  the  flask.  It  seems  impossible  to  provide  a  water-steriliz- 
ing apparatus  from  which  water  may  be  drawn  through  a  tap  in  an  absolutely  perfect  con- 
dition, for  the  tap  itself  is  constantly  exposed  not  only  to  the  atmosphere  but  to  contact  with 
hands  and  other  objects.  Still  less  easy  is  it  to  arrange  that  boiled  and  sterile  water  may  be 
led  from  a  reservoir  through  pipings  to  different  parts  of  a  building  and  delivered  at  any 
desired  point  in  a  sterile  condition,  the  difficulty  being  that  the  pipes  through  which  the 
water  is  led  cannot  be  kept  absolutely  free  from  germ-life  ;  for  spores  which  have  escaped 
destruction  in  the  first  boiling  are  liable,  before  water  is  again  drained  at  the  end  of  the 
pipe,  to  develop  more  or  less  actively  in  the  pipe  itself. 

Water,  however,  drawn  from  any  hot-water  boiler  is  sterile,  and 
may  be  freely  used  in  surgery,  provided  only  that  the  pipe  through 
which  it  is  drawn  is  frequently  flushed  out  with  boiling  water  just  be- 
fore the  supply  is  called  for.  Hospital  operating  rooms  should  there- 
fore have  close  by  them  a  boiler,  in  which  filtered  water  may  be  freshly 
boiled  every  day.  The  delivery  pipe  should  be  short  and  well  pro- 
tected. Before  using  this  water,  the  delivery  pipe  should  be  cleansed 
by  drawing  off  a  number  of  gallons  of  water. 

I/igattires  and  Sutures. — Ligatures  and  sutures  are  made  from 
catgut,  kangaroo-tendon,  silk,  silkworm-gut,  horse-hair,  and  silver 
wire. 

Catgut  approaches  most  nearly  to  the  ideal  suture  and  ligature. 
Nevertheless,  it  has  been  much  criticised,  chiefly  on  account  of  the 
great  care  required  in  its  sterilization,  and  for  this  reason  some  sur- 
geons  have  nearly  dispensed  with  its  use. 

Silk  is  more  easily  prepared,  but  its  disadvantages,  as  occasionally 
shown,  far  outweigh  the  care  necessary  in  thoroughly  preparing  catgut. 
Theoretically,  silk,  when  used  for  buried  sutures  and  ligatures,  becomes 
encapsuled  in  the  tissues,  and  remains  there  without  creating  any  sub- 
sequent disorder.  It  is,  of  course,  in  this  condition  a  permanent  foreign 
body,  and  if  the  wound  in  which  it  is  used  could  be  ideally  aseptic — 
that  is,  absolutely  free  from  bacteria  of  any  kind,  and  if  the  patient 
could  forever  remain  absolutely  aseptic,  buried  silk  sutures  and  liga- 
tures would  never  give  rise  to  disturbance  in  the  tissues.  Practically, 
however,  such  foreign  bodies  not  infrequently,  at  periods  quite  distant 
from  the  time  of  their  application,  invite  local  bacterial  disturbances 
resulting  in  abscesses  or  obstinate  sinuses. 

Catgut   which   has  been  thoroughly  prepared    and    applied   in  an 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  28 1 

aseptic  wound  and  according  to  perfect  aseptic  technic  is  soon  absorbed, 
and  rarely,  if  ever,  causes  wound-disturbance.  It  has  been  claimed  by- 
many  writers  that  catgut  may  be  absorbed  before  its  purpose  has  been 
fulfilled,  and  for  this  reason  the  use  of  a  non-absorbable  suture  has 
been  recommended.  It  should  be  remembered,  however,  that  the 
surgeon  uses  sutures  in  the  deeper  parts  of  a  wound  only  as  a  tempo- 
rary means  of  approximation,  and  that  he  really  depends  for  permanent 
union  on  the  growing  together  of  the  parts  thus  temporarily  approxi- 
mated. Such  union  of  parts  that  have  been  drawn  together  takes 
place,  if  at  all,  within  the  period  of  life  of  the  catgut ;  for  while  the 
smallest  sizes  of  catgut  are  absorbed  at  the  end  of  four  or  five  days, 
larger  sizes  may  be  used,  which,  when  properly  prepared,  last  from  ten 
days  to  three  weeks.  If  positive  union  has  not  occurred  within  such  a 
period,  non-absorbable  sutures,  which  continue  to  exert  tension,  or 
which  are  obliged  to  resist  continued  tension,  must  soon  fail  in  their 
purpose,  for  all  living  tissues  subjected  to  the  pressure  accompanying 
the  long-continued  tension  of  a  suture  yield  by  pressure-necrosis  and 
absorption.  As  a  buried  suture,  nothing  can  equal  catgut,  which  per- 
forms its  function  for  a  sufficiently  long  time  and  then  completely  dis- 
appears. If,  during  the  early  process  of  union  between  the  deep  parts 
of  a  wound,  additional  support  is  required,  it  may  be  readily  given  by 
means  of  non-absorbable  sutures,  such  as  silk,  or  silver  wire,  or  horse- 
hair, which  should  in  all  cases  emerge  through  the  skin,  in  order  that 
they  may  be  readily  removed  when  their  object  has  been  accomplished. 
It  is  probable  that  when  wound-disturbances,  such  as  skin-abscess, 
have  followed  the  application  of  catgut  which  has  been  properly  pre- 
pared, the  catgut  had  become  infected  by  handling.  No  surer  means 
of  infecting  catgut  could  be  found  than  rolling  it  between  the  finger 
and  thumb  of  a  naked  hand  while  threading  a  needle.  Even  where  it 
is  desired  to  hold  bone-fragments  together,  as  in  cases  of  fracture  of 
the  patella  or  resection  of  the  knee-joint,  heavy  catgut  answers  every 
purpose.  In  such  cases  the  suture  is  only  a  temporary  support,  and  is 
valuable  only  up  to  the  complete  application  of  the  dry  fixation-dress- 
ing. In  these  bone-cases,  absorbability  of  the  approximating  suture  is 
a  most  desirable  quality.  For  ligatures  and  all  buried  sutures  catgut 
is  certainly  to  be  highly  recommended.  With  this  opinion,  how- 
ever, many  prominent  surgeons  do  not  agree,  much  preferring,  in  all 
instances,  the  use  of  silk.  For  the  skin-suture,  which  is  not  buried,  silk 
has  superior  qualities.  Fine  silk  is  stronger  than  catgut  of  a  similar 
size.  It  is  more  pliant  and  leaves  a  neater  suture-line,  since  it  does 
not  swell,  as  catgut  does,  through  absorption  of  moisture  from  the 
tissues.  The  final  healing,  therefore,  of  the  skin-wound  has  a  better 
appearance  after  the  use  of  silk  than  after  the  use  of  catgut.  Catgut 
may  be  procured  in  skeins  about  thirty  yards  long,  numbered  accord- 
ing to  the  size.  Double  zero  is  the  smallest,  and  this  is  suitable  for 
very  fine  sutures  and  ligatures.  Single  zero  and  No.  1  are  the  next 
two  sizes,  and  these  are  sufficiently  strong  for  small  vessels  and  perito- 
neal sutures  and  for  other  cases  where  only  very  temporary  apposition 
is  required.  No.  2  forms  a  firm,  strong  suture.  Nos.  3  and  4  are  really 
heavy  and  powerful,  and  are  used  in  tying  large  pedicles  and  in  bone- 
work.     When   the  tissues  to  which  catgut  is  applied  are  exceedingly 


282  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

delicate,  such  as  omental  masses,  intestinal  surfaces,  walls  of  vessels, 
etc.,  the  suture  should  be  softened  by  immersion  for  a  few  seconds  or  a 
half-minute  in  sterilized  water  or  in  sterilized  salt  solution.  If  this  is 
not  done,  stiff  and  wiry  catgut  may  cut  directly  through  the  tissues 
which  the  surgeon  desires  merely  to  compress.  Probably  some  intra- 
peritoneal hemorrhages  occurring  after  operation  have  been  due  to 
neglect  of  this  precaution. 

Sterilization  of  Catgut. — Three  different  methods  for  the  sterilization 
of  catgut  are  here  given,  and  they  have  all  proved  to  be  satisfactory. 

The  cumol  method  is  theoretically  the  best,  as  it  is  simple  and  inex- 
pensive, and  bacteriological  experiments,  as  well  as  its  indirect  applica- 
tion, have  shown  that  it  produces  complete  sterility.  The  temperature 
of  the  fluid  during  the  preparation  of  catgut  by  this  method  requires 
careful  watching.  The  modified  form  of  the  method,  which  is  here 
given,  was  first  employed  at  the  Johns  Hopkins  Hospital,  and  is  thus 
described  in  an  article  by  Drs.  Clark  and  Miller  of  that  institution  : 

Cumol  is  an  inflammable  but  non-explosive  hydrocarbon,  with  a  boiling  point  of  about 
1700  C.  When  the  cumol  fluid  is  brought  to  a  temperature  just  short  of  its  boiling  point, 
all  spores  introduced  into  it  are  destroyed,  as  a  higher  temperature  is  reached  than  when 
alcohol  is  made  use  of,  and  there  is  no  waste  of  cumol,  as  the  fluid  is  kept  below  its  boiling 
point.  The  catgut  is  rolled  upon  glass  spools,  and  these  are  put  into  a  glass  beaker.  The 
beaker  stands  in  a  sand-bath  heated  with  a  Bunsen  burner.  A  layer  of  cotton  should  be 
placed  at  the  bottom  of  the  beaker,  on  which  the  catgut  may  rest.  The  top  of  the  beaker 
is  to  be  covered  with  a  piece  of  cardboard.  Through  a  hole  in  the  center  of  the  cardboard 
a  thermometer  passes.  Heat  is  now  applied  to  the  sand-bath,  and  the  temperature  of  the 
catgut  slowly  raised  to  8o°  C.  In  this  manner  all  moisture  is  driven  out  of  the  catgut.  This 
degree  of  heat  is  maintained  for  one  hour.  Cumol  at  a  temperature  of  1000  C.  is  now 
added  to  the  beaker,  completely  covering  the  catgut.  The  temperature  is  then  increased 
to  1650  C,  and  kept  at  that  point  for  one  hour.  The  fluid  is  now  poured  oft,  and  the 
catgut  is  allowed  to  dry  in  the  beaker  on  the  sand-bath  at  a  temperature  of  ioo°  C.  for  two 
hours.  It  is  then  to  be  transferred  to  sterile  jars  or  test-tubes  until  needed,  or  it  may  be 
preserved  in  sterile  alcohol. 

The  alcohol  method  is  applied  as  follows  :  The  alcohol  must  be  boiled  under  pressure  at 
its  normal  boiling  point,  which  is  considerably  below  ioo°  C.  This  is  easily  done,  but  the 
apparatus  must  be  made  very  accurately  and  is  expensive.  It  consists  of  a  heavy  metallic 
cylinder  or  jar,  the  top  fitting  very  perfectly  and  held  in  place  by  a  bar,  which  admits  of  the 
top  being  firmly  held  in  position  by  a  powerful  screw.  The  jar  is  partly  filled  with  absolute 
alcohol,  in  which  the  catgut  in  skeins  or  on  spools  is  immersed.  The  top  of  the  jar  is  to  be 
firmly  screwed  down  and  the  entire  cylinder  buried  in  boiling  water  for  one  hour. 

A  third  method  is  simple  and  requires  no  expensive  apparatus,  but  the  time  of  prepara- 
tion extends  over  a  period  of  several  weeks.  Glass  spools  with  the  catgut  wound  upon  them 
are  placed  in  a  jar  of  benzin  for  four  days,  then  in  a  jar  of  ether  for  two  weeks.  They  are 
next  soaked  in  oil  of  juniper  for  two  weeks,  in  order  that  all  animal  fats  may  be  removed. 
The  spools  of  catgut  are  passed  next  to  a  glass  jar  containing  absolute  alcohol  and  provided 
with  a  screw  top.  This  is  put  in  a  water-bath,  and  the  water  allowed  to  boil  for  a  half-hour. 
During  the  boiling  the  screw  top  is  only  lightly  held  in  place.  After  the  termination  of  the 
boiling  the  top  of  the  jar  is  screwed  down  tightly  and  the  jar  removed  from  the  bath.  On 
the  following  day  the  lid  should  be  loosened  and  the  boiling  for  a  half-hour  repeated,  and 
again  a  similar  process  is  gone  through  with  on  the  third  day.  During  the  three  boilings 
it  will  probably  be  found  necessary  to  add  some  fresh  alcohol  to  compensate  for  that  lost  by 
evaporation.  After  the  third  boiling,  the  lid  having  been  firmly  screwed  down,  the  catgut 
is  ready  for  use  or  for  continued  preservation. 

The  suture- jar  is  a  square  glass  box  having  a  glass  rod  running  horizontally  down  the 
middle,  which  serves  as  an  axle  on  which  the  spools  of  catgut  are  threaded.  Before  placing 
the  spools  in  the  suture-jar,  the  latter  is  sterilized  by  boiling,  and  is  then  filled  with  sterile 
absolute  alcohol.  The  catgut  may  be  reeled  off  the  spools  as  required.  During  an  opera- 
tion, sutures  and  ligatures  are  cut  with  a  pair  of  scissors  set  aside  for  that  sole  purpose,  and 
the  cut  pieces  are  kept  in  a  separate  dish.  No  instrument  which  is  being  used  in  an  opera- 
tion, no  matter  how  clean  the  case  may  be,  should  be  employed  to  cut  the  catgut  from  the 
spools  or  allowed  to  enter  the  jar.  If  these  directions  are  desirable,  how  much  more  im- 
portant is  it  that  the  sutures  and  ligatures  should  not  be  handled  with  naked  fingers  !     The 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  283 

suture-jar  has  a  close-fitting  glass  cover,  and  the  spools  may  be  allowed  to  remain  in  the  jar 
from  day  to  day  until  used. 

Chromicized  Catgut  and  Kangaroo=tendon.  —  Next  to  catgut, 
prepared  as  already  described,  the  most  popular  soluble  suture- 
materials  are  chromicized  catgut  and  chromicized  kangaroo-tendon. 
It  is  true  that,  after  they  have  been  submitted  to  a  bath  of  chromic- 
acid  solution,  catgut  and  kangaroo-tendon  are  far  less  readily  absorbable. 
This  form  of  suture-material  is  capable  of  lasting  from  four  to  six 
weeks.  The  method  of  preparing  chromicized  catgut  and  kangaroo- 
tendon  is  as  follows  : 

The  suture-material,  after  having  been  freed  from  fat,  by  being 
washed  in  ether,  is  treated  to  a  bath  of  a  4  per  cent,  aqueous  solution 
of  chromic  acid.  After  remaining  in  this  bath  for  twenty-four  hours, 
it  should  be  dried  in  a  hot-air  oven. 

The  rest  of  the  process  is  the  same  as  already  described  under  the 
head  of  the  Cumol  Method. 

Silk. — Silk  thread  of  any  reliable  make  is  suitable  for  sutures. 
Black  is  the  preferable  color,  as  it  is  most  readily  seen.  All  sizes, 
from  that  which  is  exceedingly  fine  to  that  which  is  very  heavy  and 
powerful,  can  be  obtained.  After  winding  on  glass  bobbins  or  spools, 
silk  should  be  boiled  for  a  half-hour  in  a  1  per  cent,  sodium-carbonate 
solution,  when  it  will  be  ready  for  use.  Or  this  method  may  be 
adopted  :  The  bobbins  of  silk  may  be  put  in  a  glass  ignition-  or  test- 
tube,  the  end  of  the  tube  being  plugged  with  cotton.  The  tube  is 
then  to  be  submitted  to  ten  pounds'  pressure  in  a  steam  sterilizer  for  a 
half-hour,  and  the  process  repeated  on  the  following  day.  The  test- 
tubes  are   kept  plugged   till  the  suture  is  needed. 

The  objection  to  the  simple  boiling  process  is  that  it  diminishes  the 
strength  of  the  silk,  whereas  sterilization  by  steam  under  pressure  has 
not  the  same  disadvantage. 

SiIkworm=gut. — Silkworm-gut  is  purchased  in  bundles  of  twenty 
or  thirty  strands,  which  are  about  twelve  inches  long.  The  strands 
should  be  placed  in  glass  tubes  and  submitted  to  steam  sterilization. 
Silkworm-gut  may  also  be  boiled  in  plain  water  for  a  half-hour.  A 
soda  solution  should  not  be  used,  as  it  renders  the  gut  soft  and 
swollen  and  impairs  its  strength.  Silkworm-gut  is  largely  used,  as  it 
is  much  stronger  than  catgut,  but  it  is  much  less  pliable  and  is  not 
absorbable.  It  makes  an  excellent  suture  for  skin,  as  it  is  smooth 
and  homogeneous,  not  absorbing  serum  as  silk  does,  nor  entan- 
gling bacteria.  It  possesses  some  of  the  good  properties  of  silver 
wire. 

Horsehair. — Horsehair  makes  an  excellent  suture,  and  the  finer 
grades  leave  a  very  neat  scar.  The  hairs  are  cut  into  foot  lengths,  well 
washed  with  soap  and  hot  water  and  then  rinsed  in  alcohol. 

This  material  is  sterilized  by  steam  under  pressure. 

Silver  Wire. — Silver  wire  has  its  chief  value  as  a  heavy  retention- 
suture.  Usually  sterling  wire,  of  about  No.  20  standard  gauge,  is  used. 
It  is  to  be  prepared,  after  a  thorough  scrubbing  in  soap  and  water,  by 
being  boiled,  as  the  instruments  are,  in  a  I  per  cent,  sodium-carbon- 
ate solution  for  a  half-hour,  or  it  may  be  heated  in  an  alcohol  flame. 


284  INTERNATIONAL    TEXTBOOK   OF  SURGERY. 

The  latter  method  offers  the  advantage  that  it  anneals  the  metal,  and 
thus  renders  it  less  liable  to  break  when  twisted. 

Sponges  and  Pads.  —  Sea-sponges  are  more  expensive  and 
troublesome  in  preparation  than  any  of  the  substitutes  as  an  absorb- 
ent of  fluids.  For  ordinary  use  in  removing  blood  from  the  field  of 
operation,  the  small  globular  hand-sponge,  about  two  inches  in  diame- 
ter, is  suitable.  Sponge  has  great  absorbing  power,  and  its  elasticity 
renders  it  capable  of  rapidly,  taking  up  a  large  amount  of  blood.  It 
is  also  valuable  in  forming  a  dam  or  wall  to  prevent  the  excursion  of 
septic  material  or  other  fluid  into  adjacent  portions  of  the  peritoneal 
cavity  during  operations  involving  the  abdomen.  As  it  instantane- 
ously absorbs  and  collects  fluid  which  touches  it,  no  fluid  can  pass 
it  until  the  sponge  has  become  saturated.  As  a  substitute  for  the  sea- 
sponge  most  surgeons  use  gauze  and  cotton  mops.  Such  a  mop 
is  made  with  a  six-inch  square  piece  of  gauze,  in  the  center  of  which 
is  placed  a  ball  of  absorbent  cotton  two  inches  in  diameter.  The 
gauze  is  gathered  up  about  the  ball  of  cotton  and  tied  like  a  sack 
with  a  piece  of  string.  Mops  are  less  expensive  and  easier  to  sterilize 
than  sponges,  and  some  consider  that  their  sterilization  can  be  made 
more  perfect.  They  have  the  disadvantage,  however,  that  they  do  not 
absorb  nearly  as  rapidly.  As  pads  to  keep  intestinal  coils  from  invad- 
ing the  field  of  operation,  large  flat  sea-sponges,  called  by  surgeons 
laparotomy-sponges,  are  the  most  convenient.  An  economical  and 
very  efficient  substitute  is  a  flat  gauze  pad.  These  pads  are  six  inches 
square,  and  consist  of  four  or  five  layers  of  gauze  stitched  together,  at 
one  corner  of  which  a  loop  of  tape  is  sewed.  After  the  pad  is  put  in 
place  in  the  abdomen,  a  clamp  is  put  on  the  loop,  which  prevents  the 
pad  from  being  forgotten,  and  so  unconsciously  left  behind.  Mops  and 
pads  are  sterilized  like  dressings,  and  should  be  invariably  destroyed 
after  use.  It  is  true  that  sponges  may  be  resterilized,  but  the  safer 
method  is  invariably  to  make  use  of  a  fresh  set  at  each  operation. 

Sea-sponges  are  prepared  as  follows  :  They  are  first  beaten  with  a  wooden  mallet  to  get 
rid  of  shells,  sand,  etc.,  and  are  then  soaked  in  a  solution  of  hydrochloric  acid,  1  :  64,  for 
twelve  hours.  Lime  deposits  are  thus  destroyed,  and  the  sponges  partially  bleached. 
They  are  then  to  be  washed  in  warm  water,  the  water  being  changed  frequently,  until  it 
is  no  longer  clouded  by  the  washing.  They  are  then  soaked  for  fifteen  minutes  in  a  satu- 
rated solution  of  permanganate  of  potash,  squeezed,  and  placed  in  a  warm  saturated  solu- 
tion of  oxalic  acid  ;  there  they  are  allowed  to  remain  until  every  trace  of  the  color  of  per- 
manganate has  disappeared.  Usually  this  object  will  be  accomplished  in  one  half-hour. 
A  thorough  rinsing  in  sterile  water  should  follow,  the  hands  being  covered  by  sterile  rubber 
gloves.  The  sponges  are  then  put  in  a  solution  of  1  :  1000  bichlorid  of  mercury,  and  kept 
there  for  twenty-four  hours,  from  which  solution  they  should  be  removed,  squeezed,  and 
preserved  in  sterile  jars  containing  I  :  20  carbolic-acid  solution.  At  the  time  of  operation 
a  sufficient  number  of  sponges  are  to  be  removed  from  the  jars,  squeezed  out,  and  put  in  a 
bowl  of  normal  salt  solution.  From  this  bowl  they  are  handed  to  the  surgeon  as  they  are 
required.  When  saturated  with  blood,  they  are  handed  back  to  the  nurse,  who  rinses  them 
out  in  another  bowl  of  normal  salt  solution,  when  they  may  be  again  used  as  before. 

Dressings. — The  list  of  materials  which  have  been  used  with  the 
special  object  in  view  of  absorbing  wound-discharges  is  a  very  long 
one,  almost  every  inexpensive  absorbent  material  having  been  applied 
by  one  surgeon  or  another,  either  as  an  immediate  dressing  to  the 
wound  or  as  an  enveloping  cushion  or  pad.  Oakum,  jute,  peat,  wood- 
wool, moss,  even  earth,  have  all  been  used  as  an  absorbent  dressing. 
At  present,  wound-dressings  are  represented  almost  universally  by  two 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  285 

materials — cheese-cloth,  or  what  is  commonly  called  "  gauze,"  and 
absorbent  cotton.  These  also  were  at  one  time  applied  after  having 
been  saturated  with  various  antiseptics,  such  as  bichlorid  of  mercury, 
carbolic  acid,  salicylic  acid,  boric  acid,  etc. 

In  aseptic  surgery  the  present  practice  is  to  apply  such  sterilized 
dressings  as  are  suitable  completely  to  protect  the  wound  from  trau- 
matism and  readily  and  completely  to  absorb  such  discharges  as  occur, 
recognizing  the  fact  that  as  soon  as  the  dressings  have  become  par- 
tially saturated  they  should  be  entirely  removed  and  replaced  with 
fresh  sterilized  material.  Practically,  we  find  that  discharges  absorbed 
into  sterilized  dressings  do  not  become  contaminated  through  the  air 
unless  the  dressings  have  been  left  so  long  in  place  that  they  have 
become  completely  saturated  and  the  absorbed  fluids  freely  exposed 
to  outside  influences.  As  soon  as  a  wound-dressing  has  become  satu- 
rated, or  so  clogged  with  wound-discharge  that  it  has  lost  its  original 
character  of  an  absorbent,  discharges  are  retained  in  the  wound,  and 
so  produce  all  the  evil  effects  of  septic  or  aseptic  fluids  under  tension. 

Chemical  materials  in  the  substance  of  the  dressings  do  not  favor 
the  absorbing  qualities  of  the  dressing,  and  do  not  counteract  the  evil 
effect  of  fluids  retained  under  tension.  It  is,  however,  a  clinical  fact 
that  when  iodoform  gauze  is  used  as  a  packing,  or  for  drainage  in  sep- 
tic wounds,  putrefactive  changes  in  the  discharges  take  place  less  read- 
ily than  when  simple  aseptic  gauze  is  employed.  Confidence  in  this 
preserving  quality  of  iodoform  gauze  is  far  less  complete  now  than  it 
was  a  few  years  ago,  and  surgeons  are  much  more  frequently  making 
use  of  plain  sterilized  gauze  for  wound-dressings  and  for  drainage,  even 
when  discharges  are  thoroughly  septic. 

The  commercial  term  for  gauze  is  cheese-cloth,  which  can  be  con- 
veniently cut  into  pieces  one  yard  square,  and  folded  or  rolled  up,  as 
may  be  most  convenient. 

Iodoform  gauze  is  prepared  by  dipping  plain  gauze  in  the  following  mixture  :  A  half- 
pound  of  iodoform  powder  is  mixed  with  4  ounces  of  glycerin.  Two  liters  of  thick  soap 
suds  and  the  mixture  of  iodoform  and  glycerin  are  then  stirred  together.  To  this  mixture 
are  added  two  liters  of  carbolic-acid  solution  of  the  strength  of  I  to  20.  The  quantity  thus 
prepared  is  sufficient  to  impregnate  30  yards  of  gauze.  Plain  iodoform  gauze  may  also  be 
prepared  in  a  simple  manner  by  rubbing  pure  iodoform  powder  into  the  meshes  of  ordinary 
cheese-cloth,  which  should,  of  course,  be  previously  sterilized.  Ordinary  absorbent  cotton 
is  cut  for  convenience  into  sheets  or  squares  of  various  lengths  and  sizes. 

The  Sterilization  of  Dressings. — Gauze  and  cotton,  having  been  cut  and  made  up 
into  separate  bundles,  are  wrapped  up,  carefully  pinned  in  towels,  and  placed  in  a  sterilizer. 
At  the  Roosevelt  Hospital  the  sterilizers  are  provided  with  metal  boxes,  which  rest  on 
shelves.  These  boxes  are  about  one  foot  square  and  four  inches  deep.  The  lid  is  detach- 
able. One  end  of  the  box  has  a  series  of  openings  arranged  like  the  spokes  of  a  wheel. 
On  the  outside  of  the  openings  is  placed  a  disk  revolving  on  a  central  pivot.  The  disk  is 
also  provided  with  openings  which  correspond  with  those  in  the  end  of  the  box.  A  free 
admission  of  hot  air  or  steam  into  the  interior  of  the  box  thus  takes  place.  If  the  disk  is 
given  a  partial  revolution,  the  openings  no  longer  coincide,  and  the  cavity  of  the  box  is 
excluded  from  communication  with  the  outside  air.  The  lid  of  the  box  is  so  arranged  that, 
when  the  disk  is  open,  the  lid  is  slightly  raised,  so  that  a  very  free  circulation  of  steam  is 
permitted.  When  the  disk  is  closed,  the  cover  falls  into  place  and  is  locked  down  by  the 
same  action. 

The  box  having  been  lined  with  a  towel,  the  dressings  inserted,  and  the  lid  replaced 
with  the  disk  open,  it  is  put  into  the  sterilizer,  and  the  contents  submitted  to  ten  pounds' 
pressure  of  live  steam  for  half  an  hour.  The  steam  is  then  shut  off  from  the  sterilizer  and 
allowed  to  play  without  pressure  in  the  jacket  for  half  an  hour  to  dry  the  dressings.  The 
sterilizing  process  is  repeated  on  the  following  day.      When  the  dressings  are  to  be  removed, 


2S0 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


the  sterilizer  is  opened,  and,  as  each  box  is  taken  out,  the  disk  is  turned  so  as  to  occlude 
the  openings  as  above  mentioned,  this  action  closing  the  lid  firmly  and  locking  it.  Iodo- 
form gauze  is  sterilized  and  kept  best  in  the  following  manner  :  Strips  of  this  material,  of  a 
convenient  width  and  length,  are  put  into  glass  ignition-tubes,  the  mouths  of  which  are 
plugged  with  cotton.  These  tubes  are  shaped  like  test-tubes,  about  six  inches  long  and  one 
inch  in  diameter,  and  are  made  of  heavy  glass. 

A  number  of  these  tubes,  firmly  packed  with  iodoform  gauze  and 
plugged  with  cotton,  are  put  in  a  wire  basket  which  fits  the  sterilizer, 
and  are  then  submitted  to  steam  sterilization  as  already  described. 
Towellings  and  other  loose  materials  are  packed  into  a  large  cylindrical 
basket  of  wire  which  fits  the  sterilizer  and  is  capable  of  holding  a  large 
amount  of  material. 

For  transportation  about  a  hospital,  the  boxes  such  as  described  are  sufficient.  In  pri- 
vate practice,  a  convenient  carrier  for  sterile  and  iodoform  gauze  is  a  large  glass  tube,  a 

foot  long  and  about  3  inches  in  diam- 
eter. The  mouth  of  this  tube  should 
be  somewhat  contracted,  in  order  that, 
after  it  has  been  packed  with  gauze,  it 
may  be  securely  closed  with  a  cotton 
plug.  These  tubes  are  convenient  for 
carrying  the  various  kinds  of  dry  dress- 
ings which  it  is  desired  to  keep  in  a 
sterile  condition.  The  tubes  are  packed 
with  such  materials  as  are  required, 
plugged  with  cotton,  sterilized,  and 
not  opened  until  the  contents  are  to 
be  used.  If  no  steam  sterilizer  is  at 
hand,  plain  gauze  can  be  safely  pre- 
pared by  a  simple  boiling  process,  the 
solution  used  being  a  I  per  cent,  solu- 
tion of  ordinary  washing  soda.  The 
gauze,  being  wrapped  in  a  towel  or  put 
into  a  bag,  is  thoroughly  boiled  for 
fifteen  minutes.  When  removed  from 
the  boiler,  it  is  readily  dried  by  baking 
in  an  ordinary  oven.  Absorbent  cot- 
ton can  be  sterilized  by  being  baked 
in  a  similar  manner  without  previous 
boiling.  It  should  not  be  forgotten  that, 
when  these  dry  materials  are  to  be  ster- 
ilized in  a  steam  apparatus,  they  should 
be  previously  warmed  before  the  steam 
is  turned  on,  as  cold  dressings  produce 


Fig.  57. — Large  glass  cylinders  in  which  gauze 
is  to  be  packed  and  sterilized,  the  mouth  being 
plugged  with  cotton.  Gauze  can  in  this  way  be 
carried   about   without   danger   of  infection. 


rapid  condensation  of  steam,  and  thus  become  unnecessarily  wet. 

Preparation  of  Rubber  Goods. — Articles  made  of  hard  rubber 
cannot  be  boiled  without  injury.  Pessaries,  nozzles  of  syringes,  etc., 
should  be  thoroughly  washed  in  soap  and  warm  water,  and  then  pre- 
served in  a  1  :  1000  bichlorid-of-mercury  solution.  Soft  rubber  mate- 
rials, such  as  drainage-tubes,  bulb-syringes,  etc.,  are  to  be  boiled  in 
plain  water  and  then  preserved  in  the  sublimate  solution.  What  is 
commonly  called  "  rubber  tissue"  consists  of  very  thin  sheets  of  gutta- 
percha, and  is  used  for  superficial  drainage,  for  covering  skin-grafts  or 
denuded  surfaces,  and  as  a  covering  for  outside  dressings,  to  keep  them 
moist.  This  material  should  be  thoroughly  washed  in  soap  and  water, 
rinsed  off  in  fresh  water,  and  preserved  in  a  jar  containing  a  1  :  1000 
bichlorid  solution.  The  water  which  comes  in  contact  with  gutta- 
percha must  not  be  too  hot,  as  the  material  is  very  delicate,  and  imme- 
diately shrivels  up  under  heat.     Glass  and  rubber  drainage-tubes  should 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  287 

be  washed,  boiled  for  half  an  hour  in  the  1  per  cent,  sodium-carbonate 
solution,  and  preserved  in  jars  filled  with  1  :  1000  sublimate  fluid. 

Instruments. — Instruments,  with  as  few  exceptions  as  possible, 
should  be  of  metal,  and  it  is  desirable  that  they  be  simple  in  construc- 
tion and  smooth  on  the  surface,  that  they  may  be  easily  washed  and 
rendered  perfectly  clean.  Screw  joints  do  not  meet  this  indication, 
and  when  instruments  are  made  of  two  parts,  such  as  scissors,  the 
members  should  be  joined  by  locks  or  pivots,  which  will  permit  them 
to  be  readily  separated.  Immediately  after  use,  instruments  should  be 
scrubbed  with  a  brush  and  thoroughly  washed  with  soap  and  hot 
water.  They  should  then  be  boiled  before  being  placed  in  the  instru- 
ment case.  Just  before  operations  instruments  should  be  freshly  boiled 
for  fifteen  minutes  in  a  I  per  cent,  solution  of  sodium  carbonate.  Soda 
solution  is  more  serviceable  than  plain  water,  for  the  reason  that,  in 
the  former,  instruments  do  not  rust  and  sterilization  is  more  perfect. 
Almost  any  suitable  vessel  may  be  used  as  a  boiler  for  instruments. 
It  is  convenient  to  have  the  boiler  provided  with  a  wire  basket,  in 
which  the  instruments  are  placed,  and  which  facilitates  their  removal ; 
but  if  wrapped  in  towels  or  put  into  a  bag,  instruments  may  be  per- 
fectly well  sterilized  in  any  boiler,  and  without  apparatus  especially 
designed  for  the  purpose.  Care  must  be  taken  that  during  the  boiling 
process  no  instrument  comes  directly  in  contact  with  the  bottom  of 
the  boiler.  If  this  accident  happens,  the  instrument  is  liable  to  suffer 
from  too  high  temperature.  From  the  boiler,  instruments  should  be 
transferred,  without  handling,  to  suitable  trays  containing  a  sterile  1 
per  cent,  soda  solution.  As  needles  and  knives  are  injured  by  a  pro- 
longed process  of  boiling,  these  delicate  instruments  should  be  sub- 
jected to  sterilization  for  only  five  minutes,  a  period  which  is  long 
enough  for  their  complete  sterilization.  Syringes  and  aspirators,  if 
made  entirely  of  glass  or  metal,  may  be  boiled.  If  they  have  leather 
washers  they  should  be  taken  apart,  the  glass  and  metal  portions 
boiled,  and  the  leather  parts  washed  in  soap  and  water  and  then 
rinsed  thoroughly  with  alcohol.  The  parts  of  these  instruments 
having  been  put  together,  the  whole  apparatus  is  preserved  in  a 
1:40  carbolic-acid  solution.  The  aspirator  needles  are  boiled  like 
other  instruments. 

For  transportation  it  is  convenient  to  have  metal  boxes  of  a  suitable  size,  which  can  be 
sterilized,  lined  with  cotton,  and  filled  with  instruments.  For  small  instruments,  a  conve- 
nient box  is  one  eight  inches  long,  four  inches  wide,  and  one  and  a  half  inches  deep.  The 
cover  is  just  like  the  lower  part,  and  the  sides  of  the  cover  about  the  same  depth  as  the 
sides  of  the  bottom  part.  The  cover,  being  slightly  larger,  telescopes  over  the  lower  por- 
tion. The  fitting  should  be  accurate,  in  order  that  the  box  may  be  as  nearly  air-tight  as 
possible. 

The  Preparation  of  the  Operator  and  the  Patient. — Fortu- 
nately, most  of  the  objects  that  come  in  direct  contact  with  wounds 
made  by  the  surgeon  can  be  rendered  perfectly  sterile,  and  not  only 
sterile,  but  also  non-irritating  to  the  tissues.  There  is  no  difficulty  in 
having  absolutely  sterile  clothing,  sponges,  towels,  ligatures,  sutures, 
instruments,  and  other  utensils.  If  these  sterile  objects  are  manipu- 
lated with  a  proper  regard  for  aseptic  technic,  they  never  in  themselves 
cause  disturbance  in  healing.     The  real  source  of  infection  of  a  wound 


288  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

deliberately  made  by  a  careful  surgeon  who  uses  perfect  materials  and 
handles  them  perfectly  is  to  be  sought,  with  very  rare  exceptions, 
either  in  the  skin  of  the  patient  or  in  the  hands  of  those  directly  con- 
cerned in  the  operation.  The  skin  of  the  patient  and  the  hands  of  the 
surgeon  and  his  assistants,  then,  deserve  the  most  careful  attention  pos- 
sible. The  surface  of  the  body  is  constantly  covered  with  germs  and  dust, 
and  is  also  more  or  less  soiled  with  the  various  excretions  of  the  body. 
Unfortunately,  our  most  valuable  sterilizing  agent,  heat,  is  not  entirely 
available  in  preparing  either  the  patient  or  the  surgeon,  and  we  are 
forced,  therefore,  in  such  preparation  to  depend  on  mechanical  and 
chemical  processes.  Recognizing,  therefore,  that  our  methods  are 
necessarily  imperfect,  we  should  take  the  utmost  care  to  apply  them 
thoroughly,  so  that,  as  far  as  possible,  the  special  dangers  of  wound- 
infection  may  be  avoided.  Smooth  skin-surfaces  can  be  rendered 
aseptic  with  a  fair  degree  of  certainty,  but  the  natural  apertures  of  the 
body,  skin-surfaces  which  lie  in  apposition,  hairy  areas,  and  natural 
depressions,  such  as  exist  about  the  finger-nails  and  at  the  navel, 
require  extreme  and  deliberate   care. 

Clothing. — When  preparing  for  an  operation,  it  is  the  duty  of  the 
surgeon  and  his  assistants  to  divest  themselves  of  their  outside  wear- 
ing-apparel, and  substitute  for  it  clothing  of  suitable  material  which 
has  been  properly  sterilized.  Gowns  made  of  strong  linen,  or  suits 
of  duck,  are  especially  satisfactory.  Sleeves  should  extend  not  lower 
than  the  elbow,  or,  at  least,  should  be  rolled  back  above  that  point. 
Underneath  the  gown,  a  rubber  apron  may  be  worn  for  the  protection 
of  the  underwear  from  wetting,  and  for  the  same  reason,  india-rubbers 
or  some  other  waterproof  shoe  should  be  worn  on  the  feet. 

Too  little  care  is  often  taken  in  regard  to  hair  and  beard.  These 
should  certainly  be  short,  in  order  that  they  may  be  easily  cleaned  and 
less  likely  to  drop  loose  particles  of  epidermis  upon  or  about  the 
wound.  Complete  cleanliness,  also,  suggests  the  entire  avoidance  of 
such  toilet  articles  as  are  oily  and  scented. 

The  Hands. — Of  all  of  the  objects  which  approach  the  surgeon's 
wounds,  his  own  hands  and  those  of  his  assistants  deserve  the  great- 
est attention,  and  yet,  even  to-day,  there  is  no  unanimity  in  regard  to 
the  best  method  of  sterilizing  the  hands,  and  there  still  goes  on  an 
unceasing  active  discussion,  both  among  surgeons  and  bacteriologists, 
in  regard  to  this  process.  Even  after  the  hand  has  been  brought  to 
the  condition  of  surface-sterility,  deeper  layers  of  epidermis,  such  as 
may  be  readily  opened  during  the  maceration  which  accompanies  the 
frequent  washings  during  any  large  operation,  still  contain  many  bac- 
teria. When  one  considers  the  number  of  hands  employed  in  many 
operations — often  as  many  as  ten  or  twelve — each  one  of  which  may  be  a 
source  of  infection,  the  different  qualities  of  the  skin,  the  different 
characters  and  habits  of  the  individuals,  the  different  things  that  they 
have  handled,  and  the  diseases  of  which  they  may  be  the  subjects, 
the  problem  of  providing  perfectly  sterile  hands  at  every  operation  is 
one  most  difficult  of  solution.  Many  careful  observers  claim  that  it 
is  totally  impossible  to  render  any  hand  perfectly  sterile,  and  in  this 
opinion  the  writer  heartily  concurs.  The  usual  methods  of  preparing 
the  hands  and  arms  of  the   surgeon  combine  the  use  of  mechanical 


THE    TECHXIC   OF  ASEPTIC  SURGERY.  289 

and  chemical  processes,  and,  on  account  of  the  irritating  effect  of 
chemical  antiseptics,  no  method  can  be  frequently  and  continuously 
applied  without  causing  irritation  of  the  skin.  Of  the  various  methods 
generally  in  use,  there  are  three  that  demand  special  attention,  and  in 
all  of  them,  the  first  and  most  important  step  is  the  complete  removal 
of  all  soiling  by  the  thorough  application  of  soap,  water,  and  scrubbing 
brush.  Hands  and  arms  should  be  thoroughly  cleansed  by  using 
strong  alkaline  soap,  hot  water,  and  scrubbing  brushes  that  have  been 
previously  sterilized,  in  order  to  obtain,  as  nearly  as  possible,  an  aseptic 
condition.  Scrubbing  brushes  should  be  boiled  in  a  1  per  cent,  solu- 
tion of  carbonate  of  soda  for  five  minutes,  and  then  kept  in  a  sterilized 
fluid.  While  scrubbing,  it  is  best  to  keep  the  hands  and  arms  immersed 
in  hot  water,  and  particular  attention  should  be  given  to  the  finger- 
nails, which  should  be  carefully  cleansed  with  a  good  instrument.  The 
nails  should  be  neatly  and  smoothly  trimmed,  and  loose  bits  of  epi- 
dermis completely  removed.  All  cuts,  cracks,  and  rings  interfere 
with  proper  cleansing.  Patches  of  collodion,  and  minor  dressings  of 
a  similar  character,  are  not  to  be  tolerated  on  the  hands  of  the  operat- 
ing surgeon,  for  they  are  likely  to  act  as  sources  of  infection  to  the 
wound.     Collodion  is  not  aseptic. 

First  Process. — Of  the  three  methods  in  common  use,  that  of  Fur- 
bringer  is  the  most  popular.  The  most  objectionable  feature  of  this 
process  is  the  use  of  bichlorid  of  mercury,  which  not  only  discolors 
the  hands,  but  frequently  causes  eczema,  and  leaves  the  skin  cracked, 
hard,  and  tender,  thus  forming  a  favorable  medium  for  the  growth  of 
bacteria.  Carbolic  acid  has  similar  harmful  effects.  The  details  of 
this  method  are  these:  I.  Thorough  scrubbing  of  the  hands  and  arms 
with  soft  soap  and  hot  water  for  at  least  three  minutes,  special  atten- 
tion being  paid  to  the  nails.  2.  Immersion  of  the  hands  and  forearms 
for  one  minute  in  95  per  cent,  alcohol,  the  nails  and  the  fingers  being 
thoroughly  rubbed  and  scrubbed,  in  order  that  fats  and  debris  of  all 
kinds  may  be  removed,  and  the  penetration  of  the  bichlorid-of-mercury 
solution  be  more  direct.  3.  Final  rinsing  of  the  hands  and  forearms 
in  a  bichlorid-of-mercury  solution  (1  :  1 000),  the  fluid  being  well  rubbed 
into  the  skin. 

Second  Process. —  1.  Thorough  scrubbing  of  the  hands  and  forearms, 
as  in  the  first  method  described.  2.  Soaking  in  saturated  potassium- 
permanganate  solution,  at  a  temperature  of  I  io°  F.,  until  the  skin 
acquires  a  very  dark-brown  color.  3.  Immersion  of  the  hands  and 
forearms  in  a  saturated  solution  of  oxalic  acid,  at  a  temperature  of  1  io° 
F.,  until  the  skin  has  decolorized.  Oxalic  acid  is  probablythe  most 
active  antiseptic  agent  in  this  process,  the  permanganate  of  potash 
acting  simply  as  an  oxidizing  agent.  4.  Thorough  washing  in  ster- 
ilized normal  salt  solution  or  in  ordinary  sterilized  lime  water.  5. 
Washing  in  bichlorid-of-mercury  solution  (1  :  1000)  for  one  minute, 
and  then  in  sterilized  normal  salt  solution. 

Third  Process. — The  recent  reports  made  by  Dr.  L.  A.  Stimson  in 
regard  to  a  process  which  was  first  suggested  by  Mr.  Rauschenberg, 
the  pharmacist  at  the  New  York  hospital,  have  attracted  much  atten- 
tion on  account  of  the  valuable  results  obtained  clinically.  The 
advantages  claimed  for  this  method  are  superior  sterilizing  power  and 

19 


29O  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

exceptionally  perfect  removal  of  dead  epithelium,  fat,  and  debris.     The 
process  is  as  follows  : 

1.  Hands  and  arms  to  be  washed  as  in  the  other  methods. 

2.  A  scant  tablespoonful  of  chlorinated  lime  is  to  be  moistened 
with  enough  warm  water  to  make  a  thick  paste.  This  paste  is  to  be 
applied  thoroughly  to  the  hands  and  arms,  and  carefully  rubbed  in 
about  the  nails. 

3.  A  piece  of  carbonate  of  soda,  about  an  inch  square  and  a  half- 
inch  thick,  is  to  be  crushed  and  rubbed  into  this  paste  until  the  latter 
becomes  smooth.  A  sense  of  coolness  will  then  be  experienced,  fol- 
lowing the  sensation  of  heat  previously  caused  by  the  liberation  of 
chlorin  gas.     From  three  to  five  minutes  are  thus  occupied. 

4.  The  hands  are  now  to  be  rinsed  in  sterile  water  and  washed  in 
an  aqua  ammonias  solution  of  the  strength  of  \  of  1  per  cent.,  in  order 
that  the  odor  of  chlorin  may  be  removed.  If  the  skin  becomes  irri- 
tated from  too  frequent  use  of  any  one  of  the  above  methods,  applica- 
tions of  glycerin  and  rose  water  in  equal  parts  after  operations  will 
relieve  the  discomfort. 

When  the  surgeon's  hands  are  intelligently  and  conscientiously 
cleansed  by  one  of  the  above-described  processes,  such  a  degree  of 
surface-sterility  can  be  obtained  that  bacteriological  tests  made  imme- 
diately after  the  application  of  the  process  furnish,  in  some  instances, 
95  per  cent,  of  successes.  Such  tests  may  be  made  by  removing 
scrapings  from  the  surface  of  the  hands,  especially  about  the  nails, 
and  placing  these  scrapings  in  sterilized  culture-media.  The  culture- 
tubes  are  then  placed  in  an  incubator  kept  at  a  temperature  of  8o°  F. 
In  a  few  days'  time,  the  appearance  or  non-appearance  of  bacterial 
growth  in  the  tubes  will  indicate  whether  the  scrapings  placed  in  them 
were  free  from  germ-life  or  not.  It  is  evident,  of  course,  that  when 
one  is  investigating  the  condition  of  the  entire  hand,  such  a  test  as 
this  is  a  very  partial  one  only,  not  merely  with  reference  to  the  time 
of  the  beginning  of  an  operation,  but  also  having  in  mind  what  the 
condition  of  the  hands  shall  be  in  the  middle  or  at  the  end  of  the 
operation  ;  and  it  is  evident  from  the  considerable  number  of  failures  to 
produce  even  surface-sterilization,  such  as  will  bear  the  application  of 
this  very  partial  test,  that  absence  of  sterility  of  the  surgeon's  hand  is 
liable  to  exist  at  any  time.  We  must  remember,  too,  that  in  hospital 
practice,  and  often  in  private  work,  the  hands  of  assistants  employed 
in  operations  are  frequently  changing,  and  that  every  few  months  new 
hands  are  introduced,  the  possessors  of  which  have  only  just  begun  to 
learn  the* method  of  cleansing  them.  Some  of  these  hands  come  in 
contact  with  old  wounds  and  with  foul  discharges,  and  are  necessarily 
more  difficult  to  sterilize  than  others.  Moreover,  it  is  certain  that  the 
handling  of  infected  tissues  which  accompanies  the  dressing  of  any 
but  perfectly  aseptic  wounds,  and  the  methods  of  hand-cleansing 
which  roughen  or  crack  the  skin,  render  perfect  hand-sterilization 
excessively  difficult  or  impossible.  The  hand  exfoliates  epithelium  and 
excretes  from  its  glandular  apparatus  effete  material.  It  is  quite  cer- 
tain that  we  shall  never  be  able  completely  to  sterilize  all  the  hands 
employed  in  an  operation  in  such  a  perfect  manner  that  they  will 
remain  sterile  until  the  operation  is  finished,  even  supposing  that  they 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  291 

were  in  a  perfectly  sterile  condition  at  its  commencement.  Such  con- 
siderations have  led  some  surgeons  to  look  for  a  material  capable  of 
complete  and  permanent  sterilization,  and  possessing  the  quality  of 
impenetrability  to  fluids,  with  which  the  hands  might  be  covered,  and 
thus  the  danger  of  conveying  infection  through  their  medium  to 
wounds  be  absolutely  excluded.  The  problem  has  been  solved  in  a 
most  satisfactory  manner  by  the  introduction  for  the  surgeon's  use  of 
thin,  well-fitting  india-rubber  gloves.  These  can  be  sterilized  as  per- 
fectly as  any  instrument,  for  they  permit  the  use  of  boiling  water,  or 
of  steam  under  pressure,  and  they  are  impervious  to  fluids,  either  from 
within  or  from  without.  It  seems,  then,  that  this  improved  method 
answers  very  completely  the  question  in  regard  to  hand-sterilization. 

Mikulicz's  suggestion  that  sterilized  cotton  gloves  answer  the  indication  seems  hardly 
worth  serious  consideration,  since,  although  cotton  gloves  can  be  thoroughly  sterilized,  they 
are  entirely  pervious  to  fluids,  and  the  hands  encased  in  them  must,  therefore,  if  not  abso- 
lutely sterile,  be  quite  capable  of  conveying  infection  to  the  wounds  which  they  are  hand- 
ling. A  material  pervious  to  fluid  may,  of  course,  filter  from  that  fluid  palpable  masses  of 
epithelium  or  other  foreign  material,  but  as  fluids  can  pass  from  the  wound  through  them 
to  the  hand,  and  again  return,  the  fundamental  rules  of  aseptic  surgery  are  hardly  complied 
with  when  the  surgeon  uses  material  of  this  kind  to  cover  his  hands. 

India-rubber  gloves  are  readily  prepared  for  use  in  the  following 
manner :  They  are  first  thoroughly  washed  with  soap  and  hot  water, 
to  which  a  little  aqua  ammonia;  has  been  added.  They  should  then 
be  boiled  for  fifteen  minutes  in  a  I  per  cent,  soda  solution.  Being 
carefully  removed  by  means  of  sterile  forceps,  they  should  be  laid  in 
the  center  of  a  freshly  sterilized  towel,  which  is  then  to  be  folded  over 
them.  Operator,  assistants,  and  nurses  should  put  on  fresh  gloves  for 
each  operation.  If  the  hands  are  quite  dry  and  are  then  well  rubbed 
with  sterilized  starch  powder,  or,  indeed,  with  any  finely  divided  pow- 
der, the  gloves  can  be  quite  easily  drawn  on,  even  when  their  interior 
is  moist.  The  hands  may  also  be  moistened  with  glycerin,  or  with  any 
other  lubricating  material  which  does  not  contain  oil ;  the  wet  gloves 
can  then  be  easily  put  on.  Oily  lubricants  are  damaging  to  india- 
rubber.  When  filled  with  any  sterile  fluid,  the  gloves  permit  the  hands 
to  enter  readily.  If  this  last  method  is  made  use  of,  the  hands  should 
be  first  sterilized  as  completely  as  possible,  as  the  fluid  which  fills  the 
gloves  flows  out  and  over  its  outer  surface  as  the  hand  enters.  After 
the  gloves  have  been  put  on,  their  outer  surface  should,  as  a  final  pre- 
caution, be  carefully  rinsed  off  with  sterilized  salt  solution.  The  hand 
is  then  in  a  condition  of  such  perfect  sterilization  that,  gloved  in  this 
manner,  it  may  enter  and  handle  aseptic  tissues  without  the  slightest 
danger  of  causing  infection. 

In  active  military  and  naval  service,  india-rubber  gloves  would  be 
of  the  greatest  value.  When  rolled  up  they  occupy  a  very  small  com- 
pass, can  be  transported  in  a  sterilized  condition,  and  can  be  readily 
sterilized  over  and  over  again  in  any  small  vessel  which  can  serve  as  a 
boiler.  The  best  methods  of  sterilizing  the  hands  would  be  totally 
impracticable  in  a  rapidly-filling  army  hospital,  but,  provided  with  a 
few  pairs  of  gloves,  an  army  or  navy  surgeon  need  never  dread  causing 
infection  through  his  hands  to  the  wounds  which  he  makes.  Since 
April,  1897,  the  author  has  made  constant  use  of  india-rubber  gloves 
while  operating,  having  never  operated  without  them  during  that  period. 
His  clinical  results  have  been  better  than  he  has  ever  attained  before, 


292  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

and  his  confidence  in  the  very  great  value  of  sterilized  india-rubber 
gloves  in  preventing  the  infection  of  operative  wounds  has  long  since 
become  complete  conviction.  Similar  testimony  has  reached  him  from 
a  large  number  of  operating  surgeons.  As  an  additional  precaution 
against  allowing  the  bare  skin  of  the  operator  to  come  in  contact  with 
wounds  or  instruments,  the  author  and  his  assistants  have  worn  sleeves 
for  the  forearms  made  of  two  thicknesses  of  sterilized  cheese-cloth. 

After  a  little  practice,  any  operation  can  be  done  as  well  with  rubber 
ffloves  as  without  them  ;  nor  do  the  gloves  interfere  in  the  least  with 
accurate  palpation.  When  tissue,  such  as  a  portion  of  intestine,  is  very 
slippery,  the  difficulty  is  overcome  at  once  by  the  aid  of  a  piece  of 
sterile  gauze.  If  thick  pedicles  have  to  be  tied  with  force,  a  piece  of 
gauze  in  the  palm  of  the  hand  prevents  the  ligature  from  cutting  the 
glove.  If  the  glove  finger  is  accidentally  cut  or  pricked,  the  wound 
may  be  at  once  closed  by  putting  over  it  an  extra  glove-finger.  Per- 
forations of  small  size  may  also  be  very  perfectly  mended  by  means 
of  a  rubber  cement  furnished  for  that  purpose.  A  pair  of  gloves 
handled  with  care  will  last  from  four  to  six  weeks,  even  when  used 
every  day. 

Preparation  of  the  Patient. — At  least  once  before  operation,  if  no 
contraindication  exists,  the  patient  should  be  given  a  thorough  hot 
bath  with  abundant  application  of  soap,  after  which  only  fresh  clothing 
should  be  worn.  Generally,  a  suitable  laxative  should  be  administered 
on  the  day  before  operation,  and,  on  the  morning  of  operation,  an  ordi- 
nary soap-and-water  enema  should  be  given,  so  that  the  bowels  may 
be  properly  freed  from  accumulations.  No  food  of  any  kind  should 
be  taken  within  six  or  eight  hours  of  the  time  for  the  administration 
of  the  anesthetic,  excepting  that  a  few  tablespoonfuls  of  coffee  or  a 
small  cup  of  hot  broth  may  be  given  in  the  early  morning.  Stimula- 
tion, if  indicated,  should  be  given  through  the  rectum.  The  prelimi- 
nary preparation  of  the  field  of  operation  should  be  made  in  the  follow- 
ing manner :  The-  area  cleansed  should  always  be  much  larger  in  any 
case  than  the  part  to  be  immediately  involved  in  the  wound.  This  is 
absolutely  essential,  because  towels  about  the  immediate  operative 
field  become  easily  displaced,  thereby  often  exposing  unprepared  sur- 
faces, unless  sterilization  is  carried  wide  of  the  actual  operative  wound. 
Generally,  on  the  night  before,  the  skin  should  be  carefully  shaved,  if 
hairy,  and  then  thoroughly  scrubbed  with  good  soap,  hot  water,  and  a 
sterilized  brush,  in  order  that  all  soiling  and  loose  epidermis  may  be 
removed,  and  special  care  should  be  taken  with  irregularities  of  surface, 
such  as  the  navel.     All  soapy  material  should  be  then  washed  away. 

In  the  preparation  of  callous  or  very  dirty  integument,  such  as  that 
of  the  hands  and  feet,  sterilization  should  begin  two  days  beforehand, 
the  washing  process  being  repeated  twice  daily,  and  the  parts  continu- 
ously enveloped  in  a  soap  poultice  between  the  baths.  In  all  cases,  for 
at  least  six  or  eight  hours  before  an  operation,  the  whole  operative  field 
and  its  neighborhood  should  be  covered  with  a  soap  poultice.  This 
poultice  is  made  by  taking  several  thicknesses  of  gauze  and  soaking 
them  in  a  quantity  of  soft  soap  suds  of  a  moderately  thick  consistence. 
The  water  contained  in  the  poultice  may  then  be  gently  squeezed  out 
and  the  gauze  applied  to  the  skin.  During  the  process  of  sterilization, 
the   hand   of  the  person   employed   should   be  in  a  sterile  condition. 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  293 

When  the  patient  reaches  the  operating  table,  the  poultice  is  to  be 
removed,  the  surface  washed  off  and  thoroughly  rinsed  with  hot  water. 
The  parts  should  then  be  rubbed  with  alcohol,  so  as  to  secure  the  com- 
plete removal  of  all  fatty  substances  and  other  debris,  and  finally  the 
entire  area  should  be  washed  with  a  solution  of  bichlorid  of  mercury 
(1  :  1000),  or,  better  still,  pure  sulphuric  ether.  One  should  be  careful, 
however,  and  see  that  under  no  circumstances  is  the  skin  excoriated  by 
too  rough  scrubbing1  or  by  the  too  free  use  of  chemical  applications. 
Lastly,  ulcerated  surfaces  in  or  near  the  immediate  operative  field 
should  generally  be  cauterized  with  the  Paquelin  cautery.  As  soon 
as  the  operative  field  and  its  surrounding  surface  have  been  thus  pre- 
pared, the  whole  region  should  be  immediately  covered  with  wet  steril- 
ized towels,  so  as  to  exclude  the  possibility  of  accidental  surface-infec- 
tion. The  entire  body,  excepting  such  space  as  is  required  for  operation, 
should  be  properly  protected  with  warm  coverings,  and  the  lower 
extremities  may  be  advantageously  enclosed  in  leggings.  Rubber 
sheetings  placed  over  the  blankets  or  other  coverings  prevent  the  lat- 
ter from  becoming  soaked  with  the  fluids  used,  and  over  these  are  to 
be  spread  sterilized  towels  which  have  been  moistened  with  sterile 
water.  During  the  operation  these  protecting  towels  should  be  fre- 
quently changed,  as  they  become  soiled  with  blood  or  other  materials. 
The  scalp  should  be  covered  with  a  rubber  cap,  over  which  should  be 
wrapped  a  wet  sterile  towel ;  and  the  ether  cone  should  be  protected 
with  towels  as  well.  Wet  towellings  have  a  great  advantage  over  dry 
ones,  since,  when  once  placed,  they  do  not  slip,  and  dust,  which  neces- 
sarily falls  upon  them,  is  detained  on  the  wet  surface.  If  these  direc- 
tions are  carefully  followed,  every  part  of  the  patient  excepting  his  face, 
and  every  part  of  the  table  and  of  the  unsterilized  coverings  over  the 
patient,  will  be  separated  from  the  surgeon,  his  assistants,  and  the 
operative  field  by  sterilized  material. 

Every  portion  of  the  body  which  is  to  be  operated  upon  should  be 
prepared  for  operation  in  as  sterile  a  manner  as  is  consistent  with  the 
peculiarities  of  the  region.  If  an  operation  that  involves  the  mouth  is 
to  be  done,  the  whole  cavity  of  the  mouth,  the  teeth,  and  the  pharynx 
should  be  sterilized  as  completely  as  possible.  Loose  or  decayed  teeth 
should  generally  be  removed.  The  teeth  themselves  should  be  fre- 
quently brushed  with  tooth  powder,  all  tartar  scraped  away,  and  the 
mouth  and  pharynx  rinsed  and  gargled  at  frequent  intervals  with 
suitable  cleansing  material.  For  this  purpose,  peroxid  of  hydrogen, 
one  part  in  five  or  six,  is  the  best.  Similar  methods  are  to  be  applied 
to  the  cavities  of  the  nose,  to  the  postnasal  region,  to  the  ears  and  aural 
canal,  when  any  one  of  these  regions  is  to  be  included  in  the  operative 
field.  The  removal  of  adenoid  vegetations  from  the  nasopharynx,  of 
polypi  from  the  nose  or  aural  canal,  and  all  similar  operations,  should 
never  be  undertaken  without  careful  preliminary  preparation  of  the 
parts.     The  failure  to  observe  this  rule  has  often  resulted  in  sepsis  of  a 

1  Great  care  should  be  observed  in  the  use  of  the  scrubbing-brush,  especially  while  the 
patient  is  under  the  influence  of  an  anesthetic.  If  the  surface  of  the  skin  is  broken  by  too 
energetic  scrubbing,  not  only  are  fresh  areas  prepared  for  the  entrance  of  bacteria,  but  also 
numerous  bacteria,  which  are  safely  housed  in  the  sweat-  and  hair-follicles  if  they  are  undis- 
turbed, are  set  free  to  cause  infection.  In  fact,  brushes  are  entirely  unnecessary  in  cleansing 
the  operative  area.  Soap  poultices  followed  by  gentle  washing  do  the  work  far  more 
thoroughly. 


294  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

grave  character.  The  skin  of  the  eyelids  and  the  conjunctiva  itself 
should  be  thoroughly  cleansed  before  an  operation  which  involves 
these  or  surrounding  parts,  no  matter  how  slight  the  operation.  For 
mechanical  cleansing  of  the  conjunctiva,  sterile  normal  salt  solution  is 
admirable,  as  is  also  a  warm  weak  solution  of  boric  acid.  If  the  cavity 
of  the  cranium  is  to  be  entered,  shaving  of  the  entire  head  is  never  to 
be  neglected.  Not  infrequently  the  scalp,  particularly  when  the  hair 
has  been  long  and  neglected,  is  covered  with  dense  masses  of  old 
epidermis  and  dried  discharges  from  eczema.  In  such  cases,  simply 
washing  with  soap  and  water,  or  even  the  application  of  a  soap  poultice 
for  the  usual  length  of  time,  will  not  be  sufficient,  and  to  cleanse  the 
scalp  thoroughly  it  will  be  necessary  first  to  soften  completely  the 
whole  surface  with  applications  of  sweet  oil  kept  upon  the  scalp  for  one 
or  two  days  preceding  the  final  washing.  If  sufficient  trouble  is  taken, 
and  the  hair  cleanly  shaved,  it  is  possible  to  render  the  scalp  as  clean 
as  any  other  part  of  the  body. 

When  operations  are  to  be  done  upon  the  stomach,  or  the  intestine 
immediately  below  the  stomach,  it  is  best  to  precede  the  operation  by 
a  thorough  lavage.  The  fluid  used  may  be  either  warm  water,  boric- 
acid  solution,  or  the  normal  salt  solution.  By  this  means  the  stomach 
can  be  rendered  absolutely  clean. 

Even  in  operations  on  the  pharynx  and  upper  air-passages,  the  risk 
of  infection  through  the  vomiting  accompanying  or  following  etheriza- 
tion can  be  largely  diminished  by  lavage  of  the  stomach  beforehand. 

Operations  upon  any  portion  of  the  intestinal  tract  should  be  pre- 
ceded, whenever  it  is  possible,  by  satisfactory  emptying  of  the  whole 
intestinal  canal  by  means  of  suitable  laxatives.  In  addition  to  medica- 
tion, enemata  can  be  used  with  great  advantage  whenever  operations 
are  to  be  done  upon  the  lower  bowel.  A  thorough  cleansing  of  the 
rectum  and  anus  permits  most  operations  involving  this  region  to  be 
practised  in  a  nearly  aseptic  manner.  It  is  hardly  necessary  to  mention 
that,  in  all  operations  upon  the  intestines  and  gall-bladder,  every  care 
should  be  taken  to  prevent  the  entrance  of  intestinal  contents  into  the 
peritoneal  cavity  or  upon  surrounding  coils  of  gut.  The  portion  of 
intestine  to  be  operated  upon  can  frequently  be  brought  entirely  out 
through  the  abdominal  wound,  and  so  the  whole  operation  be  made 
extraperitoneal,  or,  at  least,  the  intestine  may  be  clamped  or  tied  above 
and  below  the  part  to  be  opened  or  operated. upon,  and  so  the  passage 
of  fecal  material  by  the  seat  of  operation  be  avoided. 

Operations  upon  the  bladder  and  urethra  require  for  their  safe  per- 
formance very  complete  cleansing  of  these  organs.  The  bladder  should 
be  emptied  completely,  by  means  of  a  catheter,  at  the  last  moment 
before  operation.  It  should  then  be  filled  and  emptied  several  times 
with  some  sterile  fluid,  normal  salt  solution,  or  Thiersch's  solution. 
Ordinarily,  at  the  moment  of  an  operation  it  should  be  full  of  a  sterile 
fluid.  The  urethra,  also,  should  be  carefully  washed  out  in  a  similar 
manner.  These  precautions  should  be  taken  in  any  case  of  actual 
operation  for  the  relief  of  stricture,  and,  at  least  when  any  discharge 
from  the  urethra  exists,  the  urethra  should  be  washed  before  even  a 
sound  is  introduced.  No  sound  or  catheter  should  ever  be  made  use 
of  unless  the  instrument  is  in  a  perfectly  sterile  condition,  and  the 
orifice  through  which  it  enters  should,  of  course,  be  sterilized  as  well. 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  2g$ 

The  neglect  of  such  evidently  rational  precautions  is  constantly  leading 
to  the  establishment  of  a  more  or  less  severe  infection. 

In  using  the  instruments  just  referred  to,  it  is  desirable  to  avoid 
oily  materials  as  lubricants,  as  such  are  removed  only  with  difficulty, 
and  are  also  injurious  to  soft  rubber  materials.  Glycerin  or  lubrichon- 
drin  makes  an  excellent  lubricator,  as  each  is  soluble  in  water  and 
very  readily  removed.  After  use,  sounds  and  catheters  should  be  im- 
mediately washed  with  soap  and  hot  water.  If  kept  for  fifteen  minutes 
in  a  i  per  cent,  solution  of  sodium  carbonate  heated  nearly  to  the 
boiling  point,  the  instruments  will  not  be  injured,  and  will  be  well  ster- 
ilized. Catheters  should  be  preserved  in  a  solution  of  bichlorid 
(i  :  iooo),  all  traces  of  which  solution  should,  however,  be  washed 
away  with  hot  water  before  the  instrument  enters  the  urethra.  The 
interior  of  catheters  can  best  be  cleansed  by  the  passage  through  them 
of  boiling  water  or  live  steam. 

The  vagina,  as  well  as  the  external  genitals  of  the  female,  deserve 
especial  attention  in  all  operations  which  involve  them  ;  and  they  should 
not  be  neglected  when  operation  is  to  be  done  upon  the  anus  or  lower 
rectum.  To  cleanse  the  vagina  thoroughly  a  speculum  is  necessary, 
so  that  it  may  be  held  widely  open  while  every  portion  of  it  is  wiped 
out  with  a  sponge  on  a  long  handle,  and  vigorous  applications  of 
Thiersch's  solution  should  be  made.  If  the  interior  of  the  uterus,  or 
even  the  cervix,  is  to  be  entered  with  an  instrument,  these  tracts  should 
be  prepared  as  carefully  as  the  vagina,  and,  in  many  cases,  the  orifice 
of  the  cervix  and  its  canal  require  careful  curetting. 

Accident  Wounds. — A  large  proportion  of  accident  wounds,  such 
as  small  lacerations,  scalp  wounds,  gunshot  wounds,  and  even  com- 
pound fractures,  are  originally  nearly  aseptic,  and  remain  so  until  they 
have  been  handled  or  otherwise  actively  disturbed.  Such  wounds  fre- 
quently first  receive  officious  and  unskilful  attention  from  those  who 
make  no  pretence  at  cleanliness,  and,  by  the  time  they  come  under  the 
hand  of  the  surgeon,  are  already  infected.  The  application  of  septic 
temporary  hemostatic  apparatus  or  drugs,  ordinary  materials  used  as 
dressings,  ignorant  probing,  and  handling  with  dirty  fingers  and  instru- 
ments, more  frequently  infect  these  wounds  than  does  the  agent  of  the 
traumatism.  The  surgeon  should  therefore  treat  all  accident  wounds 
with  especial  care,  realizing  that  they  will  frequently  have  been  infected 
through  the  hands  of  some  other  person  before  they  reach  him.  More- 
over, such  wounds  are  frequently  irregular  in  outline  and  complicated 
by  lacerated  and  contused  edges.  If,  in  any  case,  it  seems  best  to 
close  such  a  wound  by  suture,  it  should  first  be  very  carefully  disin- 
fected. If  doubt  exists  in  the  mind  of  the  surgeon  as  to  the  thorough 
disinfection  of  such  wound,  it  is  far  better  to  leave  the  wound  open, 
packed  with  suitable  material  for  drainage,  than  it  is  to  apply  a  suture. 
For  the  temporary  control  of  hemorrhage  from  any  but  large  ves- 
sels in  accident  wounds,  nothing  is  better  or  safer  than  compression 
exerted  by  means  of  sterilized  gauze,  which  fills  the  wound  and  is  held 
in  place  by  a  sterile  bandage.  The  final  dressing  of  all  accident 
wounds  should  include  very  thorough  cleansing  of  the  skin  of  the 
entire  neighborhood  about  the  wound.  The  wound  itself  should  be 
washed  thoroughly  with  a  non-irritating  fluid,  such  as  normal  salt 
solution  or  Thiersch's  solution.     It  should  then  be  dried  by  the  use  of 


296  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

sterilized  gauze.  Ragged  edges  which  are  evidently  beyond  recovery 
should  be  cut  away,  undermined  edges  lifted,  and  the  underlying  spaces 
sterilized.  Whether  such  wounds  may  be  closed  by  suture  or  not 
must,  of  course,  be  decided  according  to  the  judgment  of  the  surgeon 
in  charge.  As  a  rule,  provision  for  some  drainage  should  be  made, 
and  for  this  purpose  capillary  drainage  obtained  by  means  of  gauze 
packings  is  better  than  any  arrangement  of  drainage-tubes.  Exten- 
sive, deep,  lacerated  wounds  should  under  no  circumstances  be  closed 
primarily,  and  in  a  very  large  majority  of  cases  secondary  suture  is 
far  safer  than  primary  closure.  Such  secondary  suture  may  be  well 
applied  often  on  the  second  or  third  day,  the  absence  of  infection  being 
by  that  time  determined. 

Wound -suture  and  Drainage. — Before  operation  wounds  are 
sutured,  they  should  be  carefully  washed  out  with  hot  salt  solution, 
so  that  all  blood-clots  may  be  removed.  All  oozing  points  should  be 
carefully  ligated,  preferably  with  fine  catgut,  and  all  hanging  fragments 
that  are  liable  to  necrosis  should  be  cut  away.  If  a  wound  is  to  be 
completely  closed,  the  surgeon  should  endeavor,  by  means  of  properly 
applied  sutures,  to  bring  all  raw  surfaces  in  contact  with  the  opposite 
ones,  and,  so  far  as  possible,  he  should  so  arrange  the  deep  and  super- 
ficial tissues  that  no  dead  spaces  are  left  in  which  serum  and  blood 
may  accumulate.  For  buried  sutures,  as  has  been  already  stated, 
catgut  is  to  be  preferred  to  any  other  material.  It  is  true,  however, 
that  many  surgeons  make  free  use  of  silk,  silkworm-gut,  and  even 
silver  wire,  the  objection  to  these  three  materials  being,  in  the 
opinion  of  the  writer,  a  grave  one — namely,  their  non-absorbability. 
The  different  layers  of  tissue  in  wounds  should,  as  far  as  possible,  be 
sutured  to  corresponding  layers  on  the  opposite  side.  In  some  cases, 
where  haste  is  required,  it  is  permissible  to  pass  sutures  from  the  sur- 
face through  the  entire  thickness  of  a  flap,  even  when  it  is  composed 
of  a  number  of  different  layers,  omitting  entirely,  in  order  to  save  time, 
special  suturing  of  separate  tissues.  This  method  of  suture,  however, 
is  not  likely  to  yield  as  perfect  a  cicatrix  through  the  whole  surface  of 
the  wound  as  the  separate  suture  of  tissue  to  tissue.  It  is  better  to 
avoid  placing  a  suture  than  to  place  it  where  great  tension  will  be 
caused  by  drawing  wound-edges  together,  for  continued  tension  will 
produce  either  necrosis  from  complete  shutting  off  of  blood-supply,  or 
tissue-absorption,  which  again  may  invite  the  development  and  multi- 
plication of  otherwise  harmless  bacteria.  Skin-edges  should  be  well 
supported  in  all  large  wounds  by  a  number  of  sutures  of  fairly  large 
size  which  pass  through  the  skin  at  points  \  or  \  inch  distant  from  the 
edge  of  the  wound.  These  sutures  may  be  placed  from  1  to  2  inches 
apart.  The  immediate  suture  of  the  edges  of  the  wound  should  be  as 
complete  as  possible  and  safe.  It  may  be  made  either  with  fine  catgut 
or  with  fine  silk,  the  writer  preferring  the  latter  material  for  skin- 
sutures.  Fine  silk  is  stronger  than  catgut  of  a  corresponding  size ;  it 
is  more  pliable,  and  it  leaves  a  neater  cicatrix.  For  the  strong  sup- 
porting sutures,  many  surgeons  prefer  silkworm-gut  or  silver  wire,  and 
for  the  final  immediate  skin-suture,  some  use  a  buried  fine  silk  strand, 
which  does  not  pass  through  the  skin  at  all,  but  catches  up  only  the 
immediate  subcutaneous  edge.  Theoretically,  a  perfectly  aseptic 
wound  may  be  completely  closed  without  drainage  of  any  kind,  and 


THE    TECHKIC   OF  ASEPTIC  SURGERY.  297 

this  practice  may  in  many  instances  be  followed  by  complete  success. 
It  can  be  accomplished  uniformly,  however,  only  at  the  expense  of  a 
large  amount  of  time  devoted  to  the  permanent  checking  of  all  hemor- 
rhage, however  slight,  and  by  very  complete  and  time-consuming  atten- 
tion to  the  obliteration  of  all  dead  spaces.  All  wounded  tissues  exude 
a  certain  amount  of  serum,  and  there  are  few  wounds,  no  matter  how 
carefully  attended  to,  which  are  not  followed  by  more  or  less  subcu- 
taneous bloody  oozing.  In  a  small  proportion  of  cases,  which  at  the 
time  of  closure  seem  to  be  absolutely  free  from  bleeding,  one  or  more 
vessels  will,  after  closure,  allow  of  a  considerable  hemorrhage  into  the 
tissues.  The  presence  of  pure  serum  or  blood-clot  in  the  cellular  spaces 
of  a  wound  is  certainly  an  invitation  to  bacterial  development  which, 
in  a  perfectly  empty  wound,  would  not  take  place.  Whether  it  is 
worth  while  to  accept  even  a  small  risk  of  such  accident  for  the  sake 
of  completely  closing  the  wound  in  an  ideal  manner  must  be  left  to 
the  judgment  of  each  surgeon.  Carefully  applied  drainage,  in  one 
form  or  another,  provides  against  accumulations  of  serum,  accidental 
bleeding  into  the  tissues,  and  reduces  to  a  minimum  the  chance  of 
bacterial  invasion.  The  writer  therefore  prefers  to  give  up  the  ideal 
closure  of  wounds  without  drainage  of  any  kind,  and  so  avoid  much 
loss  of  time  and  some  risk  to  the  patient.  Drainage,  therefore,  should 
be  applied  to  almost  all  wounds,  even  those  which  are  presumably 
perfectly  aseptic,  in  order  to  remove  from  the  intercellular  planes  such 
serous  or  bloody  exudations  as  are  certain  to  exist  to  a  greater  or  less 
degree.  In  aseptic  wounds,  drainage  for  the  purpose  above  mentioned 
will  have  accomplished  its  object  within  a  very  kw  hours,  and  should 
be  removed  at  the  first  convenient  opportunity.  This  is  generally 
done  at  the  first  change  of  dressings.  Such  change  might  well  be 
made  on  the  next  day  after  operation,  if  it  were  not  that  a  disturbance 
of  dressings  at  so  early  a  period  is  generally  very  uncomfortable  for 
the  patient.  As  a  rule,  therefore,  this  temporary  drainage-material  is 
most  conveniently  taken  away  at  the  end  of  about  forty-eight  hours. 
All  superficial  aseptic  wounds,  and  even  many  large  and  deep  ones, 
may  be  perfectly  drained  if  the  surgeon  introduces  at  one  or  two 
points  a  narrow  strip  of  thin  gutta-percha  tissue,  which  should  pass 
from  the  surface  to  the  deepest  portion  of  the  wound  that  requires 
emptying.  Such  strips  can  be  readily  placed  by  means  of  a  probe. 
They  should  be  from  ^  of  an  inch  to  \  inch  wide,  and  should  project 
above  the  surface  for  about  an  inch.  Serum  or  fluid  blood  will  find 
its  way  by  the  side  of  such  drainage-material  into  the  superficial  wound- 
dressing  so  that,  when  the  first  chancre  of  dressincrs  is  made,  this  mate- 
rial  will  be  found  always  to  contain  a  considerable  quantity  of  fluid, 
and  the  wound  will  be  satisfactorily  flat  and  free  from  all  accumula- 
tions. Moreover,  these  strips  of  thin  gutta-percha  never  leave  behind 
them  a  prolonged  sinus,  even  when  left  in  place  for  a  considerable 
length  of  time,  and  the  wounds  to  which  they  are  applied  heal  with 
great  rapidity.  Where,  however,  a  considerable  opportunity  exists,  as 
in  the  axilla  after  its  complete  excavation,  for  the  accumulation  of 
bloody  fluid,  it  is  safer  to  introduce  a  drainage-tube  at  a  conveniently 
dependent  point.  Such  a  drainage  tube,  if  left  too  long  in  place,  is 
likely  to  give  rise  to  the  existence  of  a  sinus  which  may  last  for  some 
little  time.     If  the  tube  is  removed,  however,  on  the  second  or  third 


298  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

day,  the  place  which  it  occupied  invariably  heals  without  difficulty. 
For  tube-drainage,  india-rubber  is  usually  the  most  convenient,  but, 
instead  of  india-rubber,  tubes  may  be  made  of  absorbable  bone,  of 
glass,  or  of  metal.  India-rubber  tubes,  from  their  pliability,  are  to  be 
preferred  in  ordinary  wounds.  Wherever  there  is  a  liability  to  com- 
pression of  the  tube  to  such  an  extent  as  to  occlude  its  caliber,  glass 
is  the  most  suitable  material.  Especially  is  this  true  where  the  pelvis 
requires  drainage  from  the  bottom  of  this  cavity  to  the  abdominal 
wall.  (  hdinarily,  cavities  requiring  drainage,  which  are  very  irregular 
in  shape,  or  have  collapsible  walls,  such  as  are  formed  by  coils  of 
intestine,  may  be  more  perfectly  kept  empty  by  capillary-drainage, 
such  as  is  furnished  by  gauze  packings,  than  by  tubes.  A  combina- 
tion of  capillary-  and  tube-drainage  is  occasionally  very  valuable. 
Such  combination,  and,  indeed,  capillary-drainage  in  general,  is  only 
required  in  septic  wounds,  or  in  those  which,  from  their  nature,  are 
liable  to  become  septic. 

In  cases  of  septic  peritonitis,  the  abdominal  cavity  having  been 
found  to  contain  a  quantity  of  turbid  fluid,  extensive  washings  with 
sterile  salt  solution,  at  a  temperature  of  from  1  io°  to  1200  F.,  are  first 
made  use  of.  Such  washing  is  capable  of  cleansing  the  peritoneal 
cavity  to  such  an  extent  that  it  is  nearly  aseptic,  but,  of  course,  all  of 
the  washing  fluid  is  never  removed ;  and  yet  it  is  desirable  that  the 
peritoneal  cavity  should  be  completely  emptied  as  soon  as  possible. 
The  remnants  of  irrigating  material,  and  also  the  fresh  exudations  of 
serum,  are  likely  to  find  their  way  into  the  pelvis,  and  can  be  best 
drained  from  this  cavity  by  means  of  a  large  glass  tube.  This  should 
be  from  \  to  f  of  an  inch  in  diameter,  open  at  both  ends,  and  long 
enough  to  extend  from  the  bottom  of  the  pelvis  to  the  surface  of  the 
abdominal  wall.  The  lower  third  of  the  tube  should  be  pierced  with 
small  holes  in  the  sides,  so  as  to  offer  a  greater  opportunity  for  the 
escape  of  fluid  from  the  pelvis  into  the  cavity  of  the  tube.  A  piece  of 
gauze  which  passes  to  the  bottom  of  the  tube  should  be  left  in  that 
situation,  and  this  will,  by  capillary-drainage,  convey  much  of  the  fluid 
to  the  surface.  After  operation,  however,  this  gauze  should  be  removed 
every  four  or  six  hours  for  a  day  or  two,  so  that  the  interior  of  the 
tube  may  be  kept  reasonably  empty.  Even  in  such  cases,  if  the  opera- 
tion has  been  well  managed  and  the  washings  made  complete,  the  wound 
is  at  once  brought  to  a  very  perfect  condition,  and  the  tubes,  if  found 
to  contain  perfectly  clean  serum  only,  may  be  safely  removed  at  the 
end  of  forty-eight  hours.  In  other  parts  of  the  abdomen  these  large 
glass  tubes  may  be  frequently  used  to  great  advantage. 

It  should  be  the  object  of  the  surgeon  in  handling  septic  wounds 
to  bring  them  as  rapidly  as  possible  to  a  clean  condition.  This  can 
be  accomplished  with  certainty  only  by  the  very  perfect  and  constant 
removal  by  drainage  of  all  septic  exudation  and  accumulation.  For 
this  purpose,  capillary-drainage  is  far  superior  to  any  other  method, 
and  complete  packing  of  such  wounds  should  be  made,  in  order  that 
the  gauze  which  is  to  serve  as  drainage  shall  lie  at  all  times  in  contact 
with  every  portion  of  the  wall  of  such  cavities,  so  that  all  fluids  may 
be  drained  off  into  the  outer  dressings.  In  actually  septic  wounds,  the 
outer  opening  should  invariably  be  wide  and  free.  Frequently,  in  such 
cases,  a  large  external  opening  with  complete  capillary-drainage  is  all 


THE    TECHNIC  OF  ASEPTIC  SURGERY.  299 

that  is  required  to  bring  such  wounds  rapidly  to  a  perfectly  clean  con- 
dition. 

Post-operative  Treatment  of  Wounds. — The  after-treatment 
of  wounds,  whether  created  by  the  surgeon  or  by  accident,  and  whether 
they  are  septic  or  aseptic,  deserves  a  close  attention  to  detail.  Wounds 
are  rarely  infected,  if  only  reasonable  care  is  taken,  at  the  time  of  the 
change  of  dressings.  Nevertheless,  it  is  quite  possible  at  this  time  by 
carelessness  to  introduce  infection,  either  through  the  agency  of  soiled 
fingers,  imperfect  dressing-material,  imperfectly  sterilized  instruments, 
or  by  contact  with  bedding  and  underclothing.  If  the  condition  of 
the  hands  employed  in  making  a  dressing  is  doubtful,  sterilized  india- 
rubber  gloves  should  be  worn  ;  and  of  course  the  dresser  and  the 
person  assisting  him  should  carefully  avoid  carrying  infection  from 
a  septic  case  to  a  clean  one.  Before  the  wound  is  exposed,  and  before 
the  deeper  dressing  is  removed,  the  bedding  and  underclothing  should 
be  excluded  from  contact  with  the  wound  by  covering  them  with  ster- 
ilized towels  or  rubber  sheeting.  The  patient's  hands  should  be  placed 
where  they  may  do  no  harm.  The  instruments  to  be  used  should  have 
been  just  sterilized,  and  all  the  dressing-material  should  be  in  a  perfect 
condition.  Implements  of  all  kinds,  such  as  bowls,  irrigators,  syringes, 
etc.,  which  are  to  be  used  in  connection  with  the  dressing,  should,  of 
course,  be  absolutely  free  from  infection.  The  dressing  may  now  be 
removed,  the  wound  properly  attended  to,  such  sutures  as  have  served 
their  purpose  removed,  and  all  skin  in  the  immediate  neighborhood  of 
the  wound-surface  thoroughly  cleansed.  For  this  purpose  hydrogen 
peroxid  is  admirable.  The  wound  should,  of  course,  be  carefully 
inspected  with  a  view  to  the  possibility  of  infection,  and  if  any  signs 
of  this  accident  present  themselves,  the  suspected  portion  of  wound, 
or  even  the  whole  of  it,  should  at  once  be  laid  open,  and  treated 
according  to  the  condition  found.  As  a  rule,  aseptic  wounds  which 
have  been  very  completely  closed  require  a  change  of  dressings  at  the 
end  of  forty-eight  hours,  in  order  that  all  material  soiled  with  discharge 
of  blood  or  serum  may  be  removed,  as  well  as  drainage-material. 
Frequently,  at  this  time,  heavy  supporting  stitches  may  be  advantage- 
ously cut.  Where  there  is  tension,  it  is  often  better  to  let  these  last- 
mentioned  stitches  remain  in  place  for  a  few  days  longer.  The  suture 
at  the  edge  of  the  skin  need  not  be  disturbed  ordinarily  before  the 
seventh  or  eighth  day.  In  the  dressing  of  such  open  wounds  as  have 
been  freely  packed,  irrigation  is  comparatively  seldom  of  value.  Dry 
cleansing  of  the  wound — that  is,  the  absorbing  of  all  fluids  by  means 
of  sterilized  gauze  or  cotton — is  generally  to  be  preferred  to  irrigation 
with  fluid.  In  any  case,  all  irritating  fluids,  which  by  their  caustic 
effects  might  interfere  with  the  production  of  granulation-tissue,  are  to 
be  avoided.  If  a  fluid  is  required  for  mechanical  cleansing,  the  safest 
material  is  normal  salt  solution.  Solutions  of  carbolic  acid  and 
bichlorid  of  mercury  are  rarely  desirable.  Actually  dead  material  had 
better  be  removed  with  scissors  at  once.  A  dressing  similar  to  that 
applied  at  the  time  of  operation  is  then  to  be  carefully  replaced.  It  is 
a  mistake  to  suppose  that  because  a  wound  has  become  infected,  and 
is  already  discharging  septic  material,  it  cannot  therefore  be  injured  by 
soiled  hands  and  by  the  use  of  infected  materials.  No  wounds  require 
greater  care  than    open    septic  ones,  and    if  the    surgeon  desires,  as 


300  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

he  must,  to  bring  them  as  rapidly  as  possible  to  a  condition  nearly 
approaching  asepsis,  he  must  treat  them  with  as  great  attention  to 
aseptic  detail  as  is  possible  under  the  circumstances. 

The  Operation. — The  manner  in  which  the  various  items  of  the 
aseptic  surgeon's  paraphernalia  must  be  prepared  has  now  been  given 
in  detail,  and  it  only  remains  to  consider  how  they  may  be  brought 
together  and  utilized,  so  as  to  be  effective  in  producing  an  aseptic 
result.  Proper  preparations  for  the  aseptic  operation  are  absolutely 
essential,  and  scarcely  less  important  are  the  system  and  manner  of 
making  use  of  the  articles  prepared.  Carelessness  in  regard  to  the 
latter  point  may  entirely  destroy  the  value  of  the  former,  for  in  the 
course  of  an  operation  a  single  neglect  of  the  clearly  defined  rules  of 
aseptic  manipulation  may  render  valueless  all  the  precautions  that  were 
previously,  and  are  subsequently,  observed.  The  one  general  rule 
must  be  that  no  object,  be  it  hand,  arm,  instrument,  sponge,  or  ligature, 
which  is  to  come  in  contact  with  the  field  of  operation,  shall,  even  on  a 
single  occasion,  touch  any  other  object  which  is  not  positively  known 
to  be  in  a  sterilized  condition.  To  observe  this  rule  requires  only  con- 
viction on  the  part  of  every  person  concerned  in  regard  to  its  impor- 
tance, for  if  the  conviction  exists,  habit  of  observing  it  is  rapidly 
acquired. 

It  is  convenient  to  begin  with  an  operation  done  in  an  ordinary 
house,  where  previously  no  special  arrangements  suitable  for  operation 
have  existed.  The  room  selected,  if  the  operation  is  to  be  done  by 
daylight,  should,  if  possible,  be  one  well  lighted  by  at  least  two  win- 
dows on  the  north  side,  as  direct  sunlight  is  dazzling  and  confusing. 
It  is  convenient  to  arrange,  if  possible,  that  the  room  selected  for  oper- 
ations shall  communicate  immediately  with  another  room,  in  which  the 
patient  may  be  anesthetized,  and,  if  possible,  a  bath-room  with  hot  and 
cold  water  should  be  close  at  hand.  Formerly,  it  was  considered 
necessary  that  the  operating  room  should  be  made  entirely  bare  of  fur- 
niture, hangings,  pictures,  carpets,  etc.  Of  course,  when  such  prepara- 
tion of  a  room  was  made,  it  was  necessary  to  begin  the  preparations  at 
least  two  days  beforehand.  After  the  room  had  been  completely 
stripped  of  furniture,  it  was  dusted  and  washed,  and  all  the  woodwork 
rubbed  with  swabs  wet  in  a  carbolic-acid  solution.  Even  the  floor  was 
treated  in  the  same  manner.  These  preparations  were  required  on  the 
theory  that  ordinary  dust  was  a  very  important  carrier  of  infection  to 
wounds,  and  that  not  only  must  every  particle  of  dust  be  removed 
from  a  room,  but  every  object,  as  well,  which  might  serve  as  a  resting- 
place  for  dust  settling  at  a  later  period  from  the  atmosphere.  It  is 
generally  acknowledged  now  that  too  much  regard  has  been  paid  to 
the  element  of  dust,  and  that  while  it  was  very  desirable  that  operations 
should  be  conducted  in  a  clean  atmosphere,  dust  which  is  at  rest  on 
objects  in  a  room,  and  which  is  not  disturbed  in  the  course  of  an  oper- 
ation, is  not  liable  to  do  injury.  All  unnecessary  furniture  had  better 
be  removed,  as  it  obstructs  walking  space,  and  is  likely  to  be  touched 
or  moved  during  the  operative  work.  Loose  hangings  which  obstruct 
light,  and  which  have  the  same  objection  that  unnecessary  furniture 
has,  should  also  be  taken  down.  Carpets  and  rugs  may  be  left  in 
place,  provided  only  that  they  are  covered  with  clean  linen  or  cotton 
in  such  a  manner  that  any  dust  which  lies  upon  them  shall  not  arise 


THE    TECHNTC   OF  ASEPTIC  SURGERY.  3OI 

into  the  air.  Any  piece  of  furniture  which  remains  in  a  room,  and 
which  is  likely  to  harbor  loose  dust,  should  also  be  properly  covered. 
The  operating  table  may  be  of  the  simplest  possible  description. 
An  ordinary  wooden  table,  5 \  to  6  feet  long,  of  a  convenient  height, 
and  with  strong  legs,  is  quite  suitable.  This  should  be  well  covered, 
first  with  blankets  for  comfort,  then  with  rubber  sheeting  to  prevent 
wetting,  and  finally,  over  all,  with  a  perfectly  clean  linen  or  cotton 
sheet.  Other  tables,  two  or  three  in  number,  covered  also  with  clean, 
freshly  laundered  material,  are  required  for  bowls  and  pitchers,  instru- 
ments, sponges,  etc.  Before  the  instrument  trays  and  bowls  for  sponges 
have  been  arranged  upon  the  tables,  the  latter  should  be  finally  covered 
with  sterilized  wet  towels.  These  tables  should  be  placed  in  convenient 
relationship  to  the  operating  table,  and  be  so  placed  about  it  that  arti- 
cles upon  them  can  be  readily  reached,  and  yet  so  that  they  shall  not 
interfere  with  freedom  of  motion  or  with  the  entrance  of  light.  A  good 
supply  of  sterile  water  must  be  at  hand,  and  this  can  be  prepared  in 
the  kitchen  or  laundry  by  boiling  ordinary  water  in  a  clean  boiler, 
which  is  to  be  brought  to  the  operating  room  long  enough  beforehand 
to  permit  it  to  cool  off  to  a  reasonable  temperature.  It  is  convenient, 
also,  to  have  a  supply  of  cold  sterile  water,  which  can  be  prepared 
some  hours  before  the  operation  by  boiling,  or  can  be  readily  purchased 
in  the  form  of  distilled  water,  a  good  sample  of  it  being  known  as 
Hygeia  Water.  Of  course,  neither  hot  nor  cold  sterile  water  should 
be  exposed  to  settling  dust  until  the  time  for  operation  arrives.  In 
private  houses,  wet  sterilized  towels  are  readily  prepared  by  boiling  a 
desired  number  for  a  half-hour  in  a  1  per  cent,  sodium-carbonate  solu- 
tion. Before  boiling,  these  towels  had  better  be  thrust  into  a  cotton 
bag  or  wrapped  in  a  clean  sheet,  so  that  the  whole  bundle  may  be 
boiled  at  once  and  easily  lifted  out  in  a  mass.  From  the  enveloping 
sheeting  they  may  be  dropped  into  a  previously  sterilized  bowl,  from 
which  they  may  be  taken  with  gloved  hands  or  with  a  clean  pair  of 
forceps,  one  at  a  time,  as  required.  The  patient  should  be  anesthetized 
in  a  separate  room,  in  order  that  the  operating  room  may  be  entirely 
at  the  disposal  of  nurses  and  assistants  up  to  the  time  of  operation.  It 
is  undesirable,  also,  that  the  patient  should  see  the  preparations  that 
have  been  made.  The  general  look  of  an  operating  room  has  upon 
some  patients  a  very  undesirable  effect.  The  patient  is  now  to  be  car- 
ried to  the  operating  room  on  a  suitable  stretcher,  hands  and  arms 
alone  not  being  satisfactory  for  this  purpose. 

A  portable  stretcher  for  use  in  private  houses  has  been  devised  by  the  writer.  It  consists 
of  two  very  light  six-and-a-half  foot  tubular  rods  of  aluminum.  These  are  hinged  in  the 
middle,  so  that  the  length  of  the  stretcher  may  be  diminished  by  one-half  for  convenience  in 
carrying.  When  at  full  length,  the  tubular  rods  are  fastened  together  by  a  transverse  one  at 
either  end,  these  transverse  rods  being  movable.  The  bed  of  the  stretcher  is  formed  by  a 
strong  piece  of  canvas.  The  whole  apparatus  can  be  folded  in  the  middle  and  then  rolled 
up,  so  as  to  make  a  small  and  light  bundle. 

The  patient  having  been  put  upon  the  operating  table,  and  all  parts 
that  need  not  be  exposed  being  warmly  covered,  thin  rubber  sheetings 
should  be  spread  over  all  excepting  the  operative  field.  These,  of 
course,  are  so  arranged  as  to  prevent  unnecessary  wetting.  Over 
these  rubber  sheetings  numerous  wet  sterilized  towels  should  be  so 
arranged  that  nothing   but  the   operative  field  remains   exposed.     If 


302  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

any  position  other  than  the  dorsal  recumbent  one  is  desired,  it  can 
readily  be  secured  by  lifting  the  head  or  foot  of  the  table  as  required, 
or  by  the  use  of  a  number  of  pillows  suitably  covered.  The  final  ster- 
ilization of  the  operative  field  should  now  be.  made,  and,  last  of  all, 
every  hand  that  is  to  be  employed  must  be  surgically  clean.  In  this 
connection,  the  value  of  rubber  gloves  may  be  again  referred  to,  for  a 
pair  which  has  been  employed  in  the  final  arrangement  of  the  patient 
and  his  clothing  may  now  be  replaced  by  one  that  is  absolutely  sterile. 
Each  individual  should  have  his  special  duties  assigned  to  him,  for  with- 
out system  and  order  in  manipulation,  it  is  impossible  to  preserve  the 
rules  of  asepsis.  Especially  in  private  work,  the  fewer  hands  that  are 
allowed  to  come  in  direct  or  indirect  contact  with  the  wound,  the  less 
likelihood  is  there  that  the  aseptic  technic  will  be  broken. 

The  instrument  table  should  have  upon  it  suitable  trays  containing 
a  i  per  cent,  solution  of  sodium  carbonate,  properly  sterilized  by  boil- 
ing, in  which  the  instruments  may  lie  immersed.  Every  instrument  that 
is  at  all  likely  to  be  needed  should  be  ready  for  instant  use,  so  that  there 
may  be  no  sudden  opening  of  any  unsterilized  packages,  a  performance 
which  always  ends  in  confusion.  Upon  the  same  table  should  be  trays 
containing  the  ligatures  that  are  to  be  used,  which  had  best  lie  in  pure 
alcohol.  The  sponges  and  pads  should  be  upon  a  separate  table,  either 
in  sterilized  bowls  or  wrapped  in  wet  sterile  towels.  At  least  two  bowls 
should  contain  several  quarts  of  hot  sterile  water,  or,  better  still,  hot 
normal  salt  solution.  Several  pitchers  of  the  same  fluid  should  also  be 
at  hand. 

When  operations  are  to  be  done  about  the  face  and  neck,  the  scalp, 
including  all  the  hair,  should  be  protected  from  wetting  by  means  of  a 
rubber  cap,  which  also  prevents  long  hair  from  getting  into  the  field  of 
operation.  This  rubber  cap  should  be  carefully  covered  with  a  sterile 
towel  as  an  additional  precaution  against  infection. 

If  the  peritoneal  region  is  the  seat  of  operation,  the  legs  and  feet  also 
should  be  covered  with  sterile  towels,  as  these  parts  are  likely  to  come 
in  contact  with  the  operator.  Similar  care  should  be  taken,  of  course, 
when  other  regions  are  to  be  operated  upon,  and  especially  must  the 
position  of  the  patient  not  be  changed  without  due  precautions  in  regard 
to  the  uncovering  of  unsterilized  parts.  Incisions  should  be  clean  cut, 
and  should  be  made  with  reference  to  the  anatomical  arrangements  of 
the  parts,  bearing  in  mind  the  function  of  the  adjacent  muscles  and 
joints  and  also  the  desirability  of  avoiding  undue  tension  when  the  time 
comes  for  suturing  the  wound-edges.  Dissections  should  be  made,  as 
a  rule,  with  sharp  knives  and  scissors,  and  not  with  blunt  instruments 
and  fingers.  The  more  delicately  and  anatomically  tissues  are  divided 
and  separated,  the  less  likely  is  necrosis  of  tissue-fragments  to  follow, 
and  the  fewer  will  be  the  unmanageable  dead  spaces  and  displaced 
muscular  planes.  Hemorrhage  should  be  carefully  attended  to  as  the 
operation  proceeds,  first,  in  order  that  as  little  blood  as  possible  may  be 
lost,  for  great  loss  of  blood  is  a  decided  invitation  to  sepsis,  and,  sec- 
ondly, that  each  succeeding  step  in  the  operation  may  not  be  rendered 
more  difficult  by  the  oozing  caused  by  the  preceding  one.  Not  only  is 
the  wound  itself  to  be  kept  constantly  free  from  fluid  and  clotted  blood, 
but  the  hands  of  the  operator  and  assistants  should  be  frequently 
washed  off  in  a  sterile  solution.     Instruments,  also,  which  are  being 


THE    TECHNIC   OF  ASEPTIC  SURGERY. 


JUJ 


used  should  be  frequently  washed  and  kept  clean.  It  is  often  desirable, 
during  the  progress  of  the  operation,  completely  to  clear  away  fluid  and 
clotted  blood.  This  can  be  done  with  sponges,  and  also  by  liberally 
pouring  into  the  wound  hot  normal  salt  solution.  This  preparation 
clears  away  blood  very  thoroughly  and  does  not  irritate  the  most  deli- 
cate tissue.  It  is  desirable,  in  short,  that  the  surface  of  the  wound,  the 
hands,  the  instruments,  and  even  the  surrounding  skin,  should  be  kept 
as  clean  as  possible — that  is,  free  from  fluid  and  dried  blood — through- 
out the  whole  course  of  the  operation.  The  sterilized  towels — which 
from  time  to  time  become  soiled — should  be  constantly  replaced  or 
covered  by  fresh  ones.  A  final  cleansing  of  the  wound  is  to  be  made 
just  before  the  suture  is  applied.  Buried  sutures  of  catgut,  preferred 
because  of  their  absorbability,  should  be  applied  to  replace  divided  tis- 
sues, as  far  as  possible,  in  their  normal  position,  but  this  rule  should  not 
tempt  the  surgeon  to  subject  the  parts  sutured  to  too  great  tension. 
The  points  where  drainage  will  be  most  efficient  or  important  will 
rapidly  define  themselves.  Small  and  superficial  spaces  can  generally 
be  quite  satisfactorily  drained  with  strips  of  thin  gutta-percha  tissue. 
Large  spaces  that  are  specially  liable  to  bloody  accumulations  had 
better  be  drained  by  a  tube,  and  wounds  which  cannot  be  properly 
closed  at  all,  or  only  in  part,  are  drained  in  a  perfect  manner  by 
means  of  greater  or  less  quantities  of  sterilized  gauze.  All  wounds 
should  have  an  abundant  dressing  placed  over  them,  the  deepest  portion 
of  which  should  consist  of  masses  of  sterilized  gauze,  thoroughly  cov- 
ered with  sterile  absorbent  cotton.  These  thick  masses  of  external 
dressing  keep  underlying  flaps  in  place,  close  empty  spaces  by  pressure, 
prevent  oozing,  and  protect  against  external  injury.  Over  the  dressing, 
binders  or  bandages  are  to  be  firmly  applied,  in  order  that  the  parts  that 
have  been  operated  upon  may  have  as  complete  rest  as  possible.  When 
the  limbs  have  been  operated  upon,  splints  placed  over  the  outer  dress- 
ings are  often  very  valuable.  After  the  wound  has  been  closed  and 
properly  dressed,  the  patient  should  be  carefully  removed  from  the 
table  to  his  bed,  wet  clothing  removed,  and  dry  blankets  wrapped  about 
him.  If  stimulation  seems  required,  it  may  be  given  at  once  by  the 
rectum,  and  a  hypodermic  injection  of  morphin  is  often  also  found  very 
desirable.  External  heat  applied  by  means  of  hot-water  bottles  is  to  be 
carefully  avoided.  In  the  first  place,  many  serious  accidents  by  burning 
with  hot-water  bottles,  while  patients  have  been  unconscious  from  the 
continued  effects  of  the  anesthetic,  have  occurred ;  and  in  the  second 
place,  there  is  no  evidence  whatever  that  external  heat  applied  in  this 
manner  ever  did  any  good.  Should  the  patient  be  sufficiently  anemic 
from  loss  of  blood  to  suggest  the  necessity  for  a  rapid  application  of 
heat,  all  the  indications  can  be  best  met  by  an  immediate  infusion  of 
hot  salt  solution  into  a  vein.  The  first  dressing  of  the  aseptically-made 
wound  is  to  be  undertaken  according  to  different  indications.  Oozing 
of  blood  to  such  a  degree  as  to  stain  the  dressings  through  at  any 
point  calls  for  an  immediate  change  of  dressing-materials.  As  a  rule, 
the  first  change  of  dressings  is  to  be  made  on  purpose  that  drainage- 
materials  may  be  taken  away,  as  they  will  rarely  be  required  after  the 
lapse  of  a  few  hours;  but  since  it  is  often  uncomfortable  for  a  patient  to 
have   his  dressings  disturbed  on  the  day  following  operation,  this  first 


304  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

dressing  may  be  conveniently  made  on  the  second  day.  Of  course,  in 
many  cases,  as  in  resections  of  joints,  it  is  desirable  to  avoid  any  hand- 
ling of  the  parts  involved,  and  in  such  cases  the  dressings  are  often  left 
undisturbed  for  a  period  varying  from  one  to  two  weeks,  especially 
when   they  are  covered  with  plaster  of  Paris  or  other  fixed  material. 

Wounds  which  the  surgeon  expects  to  treat  in  the  manner  just 
referred  to — that  is,  with  an  occlusion  dressing  which  will  probably  not 
be  disturbed  for  a  prolonged  period — should  be  closed  with  catgut 
sutures,  and  even  the  bone  suture,  as  in  case  of  resection  at  the  knee, 
should  be  of  heavy  catgut.  In  other  words,  a  foreign  material  left  in 
the  wound  should,  if  possible,  be  absorbable.  Even  drainage-tubes 
should  be  made  of  decalcified  bone.  It  is  often  more  convenient,  how- 
ever, and  amply  sufficient  to  use  as  drainage-material  strips  of  thin 
gutta-percha  tissue,  such  as  have  already  been  referred  to.  These  may 
be  left  undisturbed  in  a  wound  for  several  weeks  without  causing 
injury,  and,  when  finally  removed,  they  leave  no  sinus  behind  them,  or, 
at  least,  the  narrow  track  which  contains  such  strips  heals  with  the 
greatest  facility. 

The  details  to  be  observed  in  making  changes  of  dressings  have 
already  been  described.  Signs  indicating  that  infection  of  the  wound 
has  occurred  would,  of  course,  suggest  its  immediate  inspection,  in 
order  that  such  steps  may  be  taken  as  the  character  and  extent  of 
infection  irj&y  indicate.  The  fact,  however,  that  some  fever  is  noted  on 
the  day  after  operation  is  by  no  means  a  reliable  indication  that  infec- 
tion has  happened,  for  most  patients  within  twenty-four  or  thirty-six 
hours  after  operations  have  some  rise  of  temperature  due  to  the  rapid 
absorption  of  wound-fluids,  although  these  are  perfectly  aseptic.  The 
general  appearance  of  the  patient,  the  character  of  his  pulse,  and  the 
character  and  extent  of  his  wound-pain  will  usually  enable  one  to 
decide  whether  a  moderately  febrile  condition,  within  a  day  or  two 
after  operation,  indicates  wound-sepsis  or  not.  If  on  removal  of  the 
first  dressing  it  is  found  that  infection  of  a  wound  is  present,  sutures 
should  be  at  once  divided,  the  wound  opened  to  as  great  an  extent  as 
seems  called  for,  thoroughly  cleansed,  and  widely  drained  by  complete 
packings  with  gauze.  If  at  the  first  dressing  the  wound  is  found  to  be 
in  an  aseptic  condition,  drainage-material  is  to  be  removed,  such  sutures 
as  are  no  longer  necessary  cut,  and  a  fresh  dressing  applied,  which  need 
not  again  be  disturbed  until  the  time  comes  for  the  further  removal  of 
sutures. 

If  at  the  first  dressing  or  at  any  subsequent  period  the  wound  is 
found  to  have  become  infected,  the  attention  of  the  surgeon  should  be 
at  once  directed  to  bringing  it,  as  soon  as  possible,  to  a  perfectly  clean 
condition.  Small  drainage-openings  made  at  one  or  two  points  through 
the  suture-line  are  rarely  anything  but  disappointments.  A  small 
opening  made  into  a  more  or  less  widely-suppurating  tract  relieves 
tension  but  very  slightly,  and  almost  never  permits  the  wound  to 
become  free  from  infection.  As  a  rule,  to  which  of  course  there  are 
some  exceptions  on  account  of  special  reasons,  infected  areas  are  to 
be  very  widely  opened  as  soon  as  their  existence  is  suspected.  By  far 
the  most  important  point  in  their  treatment  is  the  complete  relief  of 
tension. 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  305 

Following  this  step,  provision  should  be  made  for  the  most  rapid 
possible  removal  by  drainage — capillary-drainage  by  gauze  packings  is 
the  best — of  every  drop  of  unhealthy  discharge  from  the  infected  sur- 
face of  the  wound.  When  an  actively-secreting  wound  is  packed  with 
dry  gauze,  the  secretions  are  at  once  absorbed  by  the  fiber  of  this 
material.  This  process  will  go  on  in  each  instance  with  perfection  and 
rapidity  until  the  packing  has  become  saturated  and  can  absorb  no 
more,  or  until  its  outer  surface  has  become  partially  dried,  and  so  the 
process  of  absorption  is  interfered  with.  The  moment  the  secretions 
cease  to  be  removed  from  the  wound-surface  with  rapidity  and  com- 
pleteness, the  wound  begins  to  suffer,  and  often,  too,  the  individual ; 
and  if  examined  at  such  a  time,  all  processes  of  repair  will  be  seen  to 
have  become  much  less  active  than  they  were.  It  is  evident,  therefore, 
that  drainage-material  which  has  been  packed  into  a  wound  should  be 
replaced  by  fresh  gauze  as  soon  as  it  has  become  saturated,  or  before 
that  moment,  if  one  would  have  the  wound  rapidly  brought  to  a  state 
of  perfection.  Infected  wounds  which  have  been  treated  by  gauze- 
drainage  should  have  their  dressings  changed  more  or  less  frequently, 
according  to  the  amount  of  discharge.  After  a  wound  has  been 
opened  on  account  of  acute  infection,  and  before  it  is  packed,  mechan- 
ical cleansing  of  some  sort  should  be  adopted,  all  discharges  should  be 
wiped  away,  loose  sloughs  and  necrotic  tissue  removed  with  the  scis- 
sors, and  general  cleansing  of  every  portion  of  the  wound  be  made 
with  some  suitable  solution. 

Formerly,  dependence  was  largely  placed  at  this  stage  in  wound- 
treatment  upon  the  vigorous  use  of  chemical  antiseptics,  such  as  car- 
bolic-acid and  bichlorid-of-mercury  solutions.  It  is  doubtful  whether 
preparations  of  this  character  have  any  especial  value  when  applied  to 
acutely  infected  wounds.  While  they  mechanically  cleanse  by  washing 
away  secretions,  just  as  any  other  solution  would  do,-  they  certainly 
cause  some  necrosis  of  granulating  tissue,  and  to  that  extent  interfere 
with  natural  processes  of  repair.  Neither  is  it  possible  by  the  use  of 
such  antiseptic  fluids  completely  to  destroy  infection  after  it  has  once 
occurred.  Normal  salt  solution  used  as  a  douche  cleanses  the  wound- 
surface  and  washes  away  secretions  without  having  any  harmful  effect. 
Such  a  mechanical  cleansing  may  be  followed  by  the  free  application 
of  hydrogen  peroxid,  which  by  chemical  combination  breaks  up  and 
.destroys  such  portions  of  the  secretions  as  have  not  been  already 
washed  away.  The  wound  is  thus  brought  into  as  clean  a  condition 
as  is  possible  under  the  circumstances,  and  is  then  to  be  packed  thor- 
oughly, although  not  tightly,  with  iodoform  or  plain  sterilized  gauze, 
as  the  surgeon  may  prefer.  If  carefully  attended  to  and  often  enough 
dressed,  infected  wounds  are  frequently  rendered  so  clean  and  so  free 
from  discharge  within  a  brief  period,  that  their  edges  may  safely  be 
brought  together  by  compression  and  allowed  to  unite.  If  the  sur- 
geon operates  and  dresses  his  wound  with  naked  hands,  he  should  be 
especially  careful  in  regard  to  cleansing  his  hands  immediately  after 
the  operation  or  dressing,  for  blood-stains  and  infectious  material  cling 
to  the  skin  with  great  tenacity  after  they  have  once  become  dry.  A 
few  drops  of  aqua  ammoniae  added  to  the  water  in  which  the  hands  are 
washed  renders  the  removal  of  blood  and  other  discharges  extremely 

20 


306  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

easy.  A  great  advantage  attaching  to  the  use  of  rubber  gloves  in 
operations  is  that  the  character  of  one  operation  or  dressing  has  no 
influence  in  determining  the  success  or  failure  of  the  next  one. 

Operating  Rooms  and  Furniture. — Rooms  such  as  are  found 
in  hospitals,  which  are  especially  constructed  and  arranged  for  that 
purpose,  may  be  divided  into  two  classes — those  which  are  intended 
for  operations  without  spectators,  and  larger  operating  rooms  or  oper- 
ating theaters,  which  are  especially  arranged  for  the  purposes  of 
demonstration.  In  both  instances  the  essential  features  are  suitable 
light,  perfect  cleanliness,  and  convenience  of  arrangements.  Direct 
sunlight  is  dazzling,  and  therefore  objectionable.  A  clear  north  light 
is  best,  and  this  should  be  supplemented  by  abundant  light  from  over- 
head. In  the  smaller  rooms,  where  spectators  are  not  expected  to  be 
present,  light  coming  from  various  directions  is  often  advantageous. 
The  construction-material  of  operating  rooms  should  be  selected  chiefly 
with  a  view  to  cleanliness,  the  color  being  largely  a  matter  of  taste, 
although  this  also  has  a  bearing  upon  illumination.  The  walls  and 
floors  should  be  of  materials  that  do  not  absorb  fluids,  in  order  that 
they  may  be  washed  with  great  thoroughness  and  frequency  without 
injury,  and  because  such  materials  also  do  not  become  offensive  to  the 
eye  by  receiving  and  holding  stains.  Floors  made  of  asphalt  are 
objectionable  because,  while  they  can  be  readily  washed,  they  are 
equally  readily  stained,  and  are  also  very  ugly  and  unsuited  in  appear- 
ance to  the  neat  fittings  of  an  operating  room. 

Floors  may  well  be  made  of  thoroughly  seasoned  wood,  of  marble 
mosaic,  or  even  of  glass.  Mosaic  floors  are  especially  suitable,  as  they 
can  be  rubbed  down  with  stone  and  sand,  and  so  be  kept  exceptionally 
clean ;  besides,  they  are  very  agreeable  to  the  eye.  A  thoroughly 
well-built  wooden  floor  is,  however,  entirely  satisfactory.  Floors 
should  be  constructed  in  such  a  manner  that  their  surfaces  incline 
slightly  toward  the  center  or  toward  several  different  points,  at  which 
a  proper  perforated  drain-opening  should  be  placed.  Free  use  of 
water  is  thus  not  restricted  by  any  difficulty  in  its  removal.  Walls 
may  be  of  marble,  glass,  wood,  hard  plaster,  or  iron.  The  three  last 
materials  require  painting,  preferably  with  a  material  of  the  nature  of 
enamel,  so  that  washing  and  rubbing  may  be  generously  indulged  in. 
The  ceiling  should  also  be  hard  and  well  painted,  and  both  walls  and 
ceiling  free  from  mouldings  and  other  irregular  surfaces  such  as  permit 
of  dust-accumulations.  Where  the  walls  join  the  ceilings  and  floors 
no  sharp  angles  or  corners  should  be  left.  These  lines  of  union  should 
be  filled  in  and  rounded  off  in  curves.  Rooms  constructed  in  this 
manner  can  be  washed  and  cleansed  at  every  point  with  great  rapidity 
and  thoroughness.  Fixed  washstands  with  an  abundant  supply  of  hot 
and  cold  water  should  be  placed  at  a  convenient  point,  and  should  be 
made  of  materials  such  as  marble,  which  do  not  absorb.  Ingenious 
arrangements  for  turning  water  on  and  off  by  means  of  foot-pressure 
are  not  necessary,  as  ordinary  faucets  can  be  handled  without  breaking 
the  rules  of  aseptic  technic  with  the  intervention  of  a  sterilized  towel 
or  a  sheet  of  sterilized  gauze.  Light  colorings  in  operative-room  con- 
struction have  a  great  advantage  that  is  at  once  appreciable.     . 

The  furniture  of  an  operating  room  may  be  made  of  hard  wood 


THE    TECHNIC   OF  ASEPTIC  SURGERY. 


307 


with  glass  tops,  but  is  better  made  of  iron  and  glass.  All  iron  material 
should  be  painted,  preferably  white,  to  avoid  rust.  An  operating  table 
with  fiat  top  is  available  for  operations  of  almost  every  description, 
different  positions  being  given  to  the  patient  by  a  proper  arrangement 
of  suitably  shaped  pillows  with  sheet  rubber. 

Tables  especially  arranged  with  a  central  drainage-opening,  and 
with  a  view  to  altering  the  position  of  the  patient  in  any  desired  man- 
ner, are  preferred  by  many  surgeons. 

The  accompanying  illustration  (Fig.  58)  represents  the  best  type 
of  table  of  the  kind  last  referred  to.     The  framework  is  of  iron  painted 


Operating  table. 


white.  The  top  is  made  of  glass,  and  is  divided  into  three  sections, 
one  for  the  head,  one  for  the  trunk,  and  one  for  the  feet.  The  head 
and  foot  pieces  are  attached  to  the  central  portion  by  hinges.  The 
center  table  is  divided  by  a  longitudinal  slit  to  provide  for  drainage. 
Attached  to  the  under  surface  of  the  top  of  the  table  is  a  large  metal 
pan  to  catch  all  drainage-fluids.  This  pan  can  be  readily  emptied  and 
kept  clean.  By  means  of  a  crank  movement  the  patient  can,  with  the 
exercise  of  very  little  power,  be  placed  in  almost  any  position. 

Generally,  the  less  complicated  in  construction  an  operating  table 
is,  the  better.  Instrument  tables,  and  tables  for  the  pails  containing 
sponges,  and  the  trays  containing  ligatures  or  sutures  may  also  be 
made  of  wood  and  glass,  or  of  iron  and  glass. 

These  should  all  be  movable,  in  order  that  their  positions  may  be 
altered  to  suit  the  convenience  of  the  operator  and  the  nature  of  the 
operation.  Every  operating  room  should  have  immediately  at  hand, 
either  in  the  room  itself  or  in  another  one  adjacent,  a  boiler  for  the 
sterilization  of  instruments.  This  may  be  needed  at  any  moment  dur- 
ing the  course  of  an  operation,  in  order  to  resterilize  instruments  acci- 
dentally infected,  or  to  sterilize  those  which  have  been  suddenly  called 
for  from  the  general  case.     Sterilizing  apparatus  for  towels  and  dress- 


308 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


ings  is  not  needed  in  the  operating  room,  because  these  materials  are 
always  prepared  beforehand.     They  should,  however,  be  not  too  far 


FlG.  59. — Operating  table. 

distant  for  convenience.     The  day  has  gone  by  for  the   use  of  expen- 
sive and  complicated  irrigation  jars  and  other  douching  apparatus,  such 

fluids  as  are  used  being  handled  more 
conveniently  and  in  a  more  cleanly 
manner  by  the  aid  of  pitchers  and 
glass  flasks.  These  are  always  to  be 
filled  with  freshly  prepared  fluid,  cold 
and  hot,  before  an  operation  begins. 
In  that  way,  their  perfect  steriliza- 
tion can  be  guaranteed.  Long  india- 
rubber  tubes  for  irrigating  purposes, 
fountain  syringes,  and  all  hanging 
apparatus  of  a  similar  kind  are  ob- 
jectionable on  account  of  the  likeli- 
hood of  infection  and  the  difficulty 
of  sterilization. 

The  general  instrument  case  may 
be  in  the  operating  room,  or  not,  ac- 
cording to  convenience  and  the  size 
of  the  building.  It  is,  of  course, 
better  that  there  should  be  a  spe- 
cial room  for  the  continual  storing 
of  instruments.  Splints,  blankets, 
plaster  bandages,  and  all  materials 
^P  that  are  liable  to  harbor  dust  and 
are  not  readily  sterilized  should  be 
FiG.6o.-Bowi  to   stand  by  operator,    exciuded  from  the  operating    room 

containing     sterilized     fluid,    for    frequent  11 

hand-washing  during  operation.  until   the     moment    when    they    are 

needed. 
It  is  well  to  have  two  or  three  benches  made  of  wood,  of  different 


THE    TECHNIC   OF  ASEPTIC  SURGERY.  309 

heights,  upon  which  the  operator  may  stand  whenever  he  wishes  to 
change  his  relation  to  the  patient  by  raising  or  lowering  himself.  If 
fixed  washstands  are  set  at  some  little  distance  from  the  operating  table, 
some  arrangement  should  be  made  so  that  the  operator  may  at  any 
moment  turn  from  the  table  and  cleanse  his  hands  of  blood  or  other 
fluids  in  a  sterilized  solution.  A  small  table,  supporting  a  bowl  filled 
with  sterile  salt  solution  which  can  be  frequently  changed,  will  serve 
the  purpose,  or  a  special  iron  framework  bearing  a  bowl  made  for  the 
purpose  may  be  supplied. 

Every  operating  room  should  be  provided  with  absolutely  satisfac- 
tory artificial  light,  such  as  will  perfectly  take  the  place  of  daylight, 
if  the  day  happens  to  be  a  dark  one,  or  if  an  operation  is  to  be  done 
after  daylight.  A  combination  of  electricity  and  gas  furnishes  an 
admirable  light  and  provides  against  all  accidents.  In  addition  to  the 
fixed  light,  which  should  be  directly  over  the  operating  table,  there 
should  always  exist  a  movable  light,  preferably  electric,  which  can  be 
held  by  an  assistant  so  as  to  illuminate  any  particular  region  or  cavity 
which  the  operator  desires  to  inspect. 

Operating  Theaters. — Operating  rooms  that  are  intended  especially 
for  purposes  of  demonstration,  in  which  accommodation  for  a  consider- 
able number  of  spectators  is  required,  have  to  be  constructed  on  a 
somewhat  different  plan.  In  the  first  place,  the  illumination  of  such 
rooms  should  be  arranged  with  a  special  view  to  the  comfort  of  the 
spectators.  Every  individual  looking  at  an  object  sees  most  perfectly 
when  the  rays  of  illumination  are,  as  nearly  as  possible,  parallel  with 
the  line  of  vision.  All  light  which  enters  the  room  behind  the  object 
looked  at,  or  which  reaches  the  eye  of  the  spectator  more  or  less 
directly  from  the  side,  serves  only  to  diminish  the  power  of  vision. 
The  principal  light  in  an  operating  theater  should  therefore  come  from 
the  north  and  enter  the  room  just  above  and  behind  the  spectators. 
As  spectators  are  naturally  looking  somewhat  downward  during  an 
operation,  additional  light  may  be  let  in  from  above,  but  all  side-lights 
and  all  light  entering  from  behind  the  operating  space  should  be  rigidly 
excluded.  The  arrangement  just  recommended  is  not  the  most  agree- 
able for  the  operator,  but  it  serves  the  purpose  of  his  demonstration 
better  than  any  other.  Seats  for  spectators  should  be  arranged  upon 
an  inclined  plane,  the  angle  of  which,  in  relation  to  the  horizontal, 
should  be  such  that  no  one  individual  can  in  any  way  interfere  with  the 
vision  of  another  sitting  behind  him.  No  accommodation  should  be 
provided  for  a  larger  number  of  spectators  than  can  see  accurately 
every  detail  of  the  operative  work.  The  floors  and  seats  of  the  audi- 
torium should  be  of  such  materials  as  can  be  perfectly  and  freely 
washed.  The  floor  may  be  of  asphalt  or  of  thoroughly  laid  and  shel- 
laced wood.  The  seats  should  be  of  wood,  that  being  the  only  mate- 
rial which  can  be  thoroughly  cleansed  and  which  is  also  comfortable  to 
sit  upon  for  any  length  of  time.  These  seats  should  be  supported  upon 
single  pillars,  or  otherwise  so  arranged  that  water  may  be  thrown  with 
a  hose  over  the  entire  floor.  If  dependence  for  cleansing  such  a  floor  is 
placed  upon  brooms  and  mops,  such  cleansing  will  certainly  be  imper- 
fectly done  and  will  also  be  exceedingly  laborious  and  time-consuming. 
At  two  or  more  points  in  an  auditorium  water-pipes  should  open,  to 


3io 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


which  hose  can  be  attached,  and  thus  the  whole  floor  be  easily  and 
rapidly  washed.  Such  arrangement  necessarily  requires  a  provision  for 
drainage,  openings  for  which  should  be  placed  at  the  foot  of  the  inclined 
plane,  in  order  that  fluid  may  be  rapidly  carried  off  as  soon  as  it  has 
reached  the  lower  edge  of  the  floor.  The  operating  space  should  be 
securely  walled  off  from  the  auditorium  proper,  in  order  that  no  indi- 
vidual may  be  tempted  to  pass  from  one  area  to  the  other.  This  seems 
to  be  absolutely  essential  in  order  to  preserve  complete  freedom  from 
contact  between  spectators  and  those  immediately  engaged  in  the 
operation. 

Special  care  must  be  taken  that  spectators  do  not  through  ignorance 
or  carelessness,  such  as  the  placing  of  their  feet  upon  the  edge  of  this 
dividing  wall,  contaminate  the  operating  space  and  the  things  contained 
in  it.  The  operating  space  should  be  arranged  in  a  somewhat  different 
manner  from  that  of  a  room  in  which  no  spectators  are  to  be  provided 
for.  It  should  be  as  small  as  the  convenience  and  rapid  working  of  the 
operator  and  his  assistants  will  permit  of,  for  the  larger  the  operating 
space,  the  more  distant  will  the  spectators  be  from  the  object  at  which 
they  are  looking.  The  smaller  the  space  the  nearer  are  the  spectators 
brought  to  the  operating  table.  Therefore,  provision  should  never  be 
made  for  the  performance  of  more  than  one  operation  at  the  same  time. 
Moreover,  the  attention  of  spectators  is  distracted  by  having  different 
pieces  of  work  going  on  simultaneously,  and  the  rules  of  asepsis  are 
very  likely  to  be  broken. 

The  tables  for  instruments  and  ligatures  must  be  movable,  and  are 
to  be  so  placed  as  not  to  interfere  with  the  vision  of  the  spectators. 
They  should   therefore   be   brought   more  or  less  to  the  rear  of  the 

operating  table ;  this  disposition  of 
them  forces  the  assistants  and 
nurses  in  the  same  direction,  thus 
leaving  the  interval  between  operator 
and  audience  entirely  unobstructed. 
As  the  operating  space  is  small,  and 
as  all  preparations  for  public  demon- 
strations are  naturally  carefully  made 
on  a  large  scale  before  the  time  for 
operation,  all  apparatus  not  indispen- 
sable to  the  proper  immediate  man- 
agement of  an  operation  should  be 
excluded  from  the  operating  room. 
Chairs,  unnecessary  tables,  boilers, 
and  all  such  appliances  are  out  of 
place  on  such  occasions. 

The  remaining  furniture  of  the 
operating  room  should  consist  of 
three  or  four  iron  stands  with  glass 
shelves  and  tops,  mounted  on  rollers 
to  admit  of  their  being  shifted  about  the  room.  These  stands  are  for 
instruments,  suture-trays,  towels,  etc. 

Any  extra  furniture,  such  as  wash-stands  or  shelves,  should  be 
placed  entirely  out  of  the  way  in  the  rear.     The  floor  of  the  operating 


Fig.  6i. — Iron  and  glass  table  for  dressing 
materials. 


THE    TECH  NIC    OF  ASEPTIC  SURGERY. 


311 


space  may  be  of  any  suitable  material,  preferably  marble  mosaic,  which 
is  non-absorbing  and  is  very  readily  cleansed.  In  this  floor  there 
should  be  special  drainage-openings  toward  which  the  floor  must 
slightly  incline,  and  the  openings  should  be  placed  at  points  more  or 
less  distant  from  the  operating  table.  The  artificial-light  apparatus 
should  be  so  arranged  that  it  may  be  swung  out  of  the  way  when 
not  in  actual  use.  If  stationary  and  hanging  directly  over  the  oper- 
ating table  at  all  times,  it  serves  as  a  dust-accumulator  at  a  very  unde- 
sirable point.  If  deficiency  of  daylight  requires  that  the  apparatus  be 
swung  into  place  while  an  operation  is  going  on,  the  entire  operative 
area  should  be  carefully  covered  with  sterilized  towels  during  this 
change.  Of  course,  strictly  speaking,  the  lighting  apparatus  should  be 
kept  as  clean  and  free  from  dust  as  any  other  piece  of  furniture. 

It  follows  from  this  description  of  an  operating  theater  that  other 
rooms  must  exist  in  immediate  connection  with  it  for  the  storing  of 
instruments,  the  sterilizing  of  dressings,  the  washing  of  apparatus,  and 
for  the  preliminary  preparations  of  operator,  assistants,  and  nurses.  If 
an  operating  room  is  to  be  complete  in  every  particular,  there  must  be 
in  close  connection  with  it  a  considerable  number  of  rooms,  all  of  which 
contribute  to  the  needs  of  the  operating  room  itself.  The  essential 
rooms  to  accomplish  this  purpose  may  be  enumerated  as  follows  :  At 
least  two  etherizing  rooms,  lavatory  for  surgeon  and  assistants,  instru- 
ment room,  room  for  washing  instruments,  .sterilizing  room  for  dress- 
ings, instruments,  and  water,  room  for  storage  of  dressings,  room  for 
the  preparation  of  dressings,  room  for  splints,  plaster  of  Paris,  and  rough 
materials  of  all  kinds.  Of  course,  according  to  the  amount  of  work 
done  in  an  operating  room,  and  according  to  the  possibilities  in  indi- 
vidual instances,  variations  in  the  number  and  arrangement  of  rooms 
may  easily  be  made.  For  instance,  instruments  may  be  stored,  washed, 
and  sterilized  in  the  same  room ;  bandages  and  dressings  may  be  pre- 
pared, stored,  and  sterilized  in  another  room,  and  a  single  etherizing 
room  will  answer  the  needs  of  any  but  a  very  active  service.  But  what- 
ever arrangement  of  room  is  made,  perfect  system  and  order  should 
be  maintained,  so  that  the  least  temptation  possible  may  exist  to  break 
the  rules  of  asepsis. 


CHAPTER    XII. 
OPERATIVE  AND  PLASTIC  SURGERY. 

Instruments. — Instruments  should  be  of  the  best  quality  and 
carefully  selected.  There  is  no  economy  in  buying  cheaper  instru- 
ments. Surgeons  should,  so  far  as  possible,  learn  to  work  with  simple 
tools.  Multiplicity  or  complexity  of  instruments  for  any  given  opera- 
tion should  be  avoided.  All  instruments  should  be  made  entirely  of 
metal,  with  smooth,  plain  surfaces ;  and  all  jointed  instruments,  such 
as  clamps  or  scissors,  should  have  a  simple  pivoted  French  lock. 
Screw-joints  are  not  advisable,  as  instruments  having  them  are  not  easy 
to  clean.  For  all  ordinary  dissections,  what  is  known  as  a  simple 
dissecting-outfit  is  all  that  is  needed.  This  will  consist  of  knives, 
straight  and  curved  scissors,  two  pairs  of  toothed  dissecting-forceps 
(see  Fig.  62),  two  pairs  of  dissecting-forceps  without  teeth,  one  aneu- 


FlG.  62. — Toothed  dissecting-  or  artery-forceps. 

rysm-needle  or  Cleveland  ligature-carrier  (Fig.  63),  a  director  or  blunt 
dissector,  plenty  of  hemostatic  or  artery-clamps  (Fig.  64),  and  some 
simple  form  of  retractor.  Special  operations  require  occasionally  spe- 
cial instruments,  the  choice  of  which  will  depend  on  the  operation  in 
hand. 

The  knives  for  ordinary  dissecting  should  be  of  medium  size,  light 
in  weight,  with  metal  handles,  and  with  a  moderately  tapering  blade 
(Fig.  65).  (Special  knives  are  considered  under  the  head  of  Amputa- 
tions, p.  329.) 

Forceps  should  be  strongly  made,  and  must  not  be  too  narrow  at 
the  points.  Those  with  two  teeth  are  preferable.  The  strength  of  the 
spring  can  be  varied  to  suit  the  operator.  Artery-forceps,  known  as 
pressure-forceps  or  hemostatic  forceps,  are  all  modifications  of  the 
Spencer-Wells  clamp-forceps  (Fig.  64).  They  are  indispensable  in 
securing  blood-vessels  during  an  operation.  They  should  be  of  differ- 
ent sizes,  and  with  both  straight  and  curved  blades,  should  be  strongly 
made,  and  should  have  a  simple  pivot  lock. 

P.12 


OPERATIVE  AND  PLASTIC  SURGERY.  313 

Retractors  play  an  important  role  in  holding  back  superficial  struct- 


FlG.  63. — Cleveland  ligature-carrier. 

ures  and  giving  access  to  the  deeper  tissues.     There  are  many  varie- 
ties.    A  good  retractor  should  secure  a  firm  hold  on  the  tissues  to  be 


FlG.  64. — Hemostatic  forceps. 

held  back,  but  should  be  so  constructed  as  to  inflict  the  least  possible 
amount  of  injury  to  the  parts.     Any  form  of  right-angled  blunt  retrac- 


Fig.  65.— Scalpel. 

tor  of  the  proper  size  may  be  used  (Figs.  66  and  67),  but  those  with 
sharp  teeth  had  better  be  avoided. 


3U 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


Needles. — For  suturing  skin-flaps,   the   best    form   of  needle   is  a 
medium-sized  glover's  needle — a  straight  needle  with  triangular  cut- 


vmxt^^^^^^a¥s^\^M\\^\\Mi^V>mww^Wl^^ff^> 


FlG.  66. — Small  right-angled  retractor. 


ting-edges.     In  place  of  this,  a  straight  lancet-pointed  or  surgeon's 
needle  can  be  used.     Hagedorn  needles,  straight  or  one-half  curved, 


Fig.  67. — Retractor  for  deep  wounds. 

are  preferred  by  many  surgeons  for  plain  flap-sutures.  For  intestinal 
work,  ordinary  sewing-needles,  without  a  cutting-edge,  should  be  used. 
These  may  be  straight  or  curved.  For  most  intestinal  work  the 
straight  needles  suffice,  but  in  some  deep  suturing  the  curved  are 
needed.  Curved  needles  are  often  useful  for  approximation  of  deep 
tissues,  muscles,  fasciae,  tendons,  etc.  For  this  a  strong  curved  needle 
with  a  bayonet-point,  or  a  curved  Hagedorn,  is  best.  In  small  needles, 
especially  of  the  intestinal  variety,  those  with  the  calyx  eye,  the  self- 
threading  type,  are  time-saving. 

Sutures  and  Ligatures. — Silk,  silkworm-gut,  and  catgut,  or  some 
form  of  animal  tendon,  are  the  chief  kinds  used  by  all  surgeons.  Silver 
wire  has  a  limited  use.  Ligatures  may  be  either  silk  or  catgut.  In 
aseptic  wounds  there  can  be  no  objection  to  silk.  It  can  be  readily 
sterilized  and  is  easily  handled.  In  septic  wounds  catgut  is  desirable, 
because  of  the  tendency  of  silk  to  cause  sinus-formation.  For  the 
approximation  of  deeper  tissues,  as,  for  instance,  in  hernia,  kangaroo- 
tendon,  or  animal  tendon  in  some  other  form,  makes  a  desirable 
absorbable  material.     For  the  suturing  of  skin-flaps,  silkworm-gut  is 


OPERATIVE  AND   PLASTIC  SURGERY. 


315 


the  ideal  substance.  It  is  non-absorbent,  non-irritating,  and  readily 
sterilized.  For  very  fine  skin-sutures  and  especially  in  plastic  opera- 
tions on  the  face,  sterilized  horsehair  will  be  most  suitable.  (For  the 
detailed  methods  of  sterilization  of  instruments,  ligatures,  and  suture- 
material,  see  pages  282,  283.) 

Technic  of  Dissection. — Operations  should  be  done  deliber- 
ately, and  should  be  governed  by  fixed  principles.  The  skin-incisions 
should  be  of  liberal  length  and  cleanly  made.  All  deep  dissections 
should  be  done  under  perfect  visual  control.  Hemorrhage  and  undue 
injury  to  the  tissues  should  be  avoided.  The  incision  should  be 
carried  downward,  layer  for  layer,  by  careful  strokes  of  the  knife. 
Blunt  dissection,  or  tearing  of  the  tissues  with  a  director  or  the  fingers, 


Fig.  68.— Knife  held  like  a  penholder. 


FIG.  69. — Knife  held  like  a  violin-bow. 


Table-knife  position. 


should  be  done  as  little  as  possible.  The  best  method  of  dissection  is 
that  of  cutting  between  two  forceps.  If  the  various  layers  of  tissue  are 
picked  up  by  two  forceps,  they  are  put  on  the  stretch  and  the  vessels 
readily  seen. 

The  different  ways  of  holding  the  knife  are  shown  in  Figs.  68-70. 

The  skin-incision  can  be  made  freely  and  with  a  firm  hand  ;  but  as 
the  dissection  advances  and  important  vessels  are  approached,  the 
knife  should  be  held  like  a  pen,  and  the  cuts  made  carefully  and 
entirely  with  the  point. 

Arrest  of  Bleeding. — Hemostasis  should  be  attended  to  with 
scrupulous  care  during  each   stage  of  the  operation.     Wherever  possi- 


3 16  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

ble,  vessels  should  be  double-clamped  with  pressure-forceps  before 
being  divided.  All  bleeding  points  should  be  secured  with  hemostatic 
forceps.  Many  of  the  smaller  vessels  require  no  ligature  after  being 
compressed  for  some  time.  Especially  is  this  true  of  the  vessels  in  the 
skin-flaps.  In  case  of  doubt,  it  is  a  safe  rule  to  ligate  all  points  that 
have  been  caught  during  the  operation,  for  many  small  vessels  which  do 
not  show  signs  of  bleeding  on  removing  the  artery-clamps  may  bleed 
when  the  reaction  from  the  operation  and  anesthetic  begins.  Torsion  of 
the  smaller  vessels  is  not  a  reliable  means  of  hemostasis.  In  certain 
instances  of  venous  oozing,  and  especially  in  operations  on  inflamed 
and  friable  tissues,  it  may  be  necessary  to  pass  a  ligature  in  a  curved 
needle  around  the  bleeding  spot  and  control  the  hemorrhage  by  con- 
stricting a  comparatively  large  area.  Many  cases  of  slight  general 
oozing  can  be  checked  by  temporary  pressure  with  gauze  pads,  or  by 
the  use  of  hot  sterile  water  or  salt  solution.  In  exceptional  cases, 
where  large  areas  of  inflamed  tissue  are  denuded,  it  may  be  necessary 
to  use  the  actual  cautery. 

THE    LIGATURE  OF  ARTERIES. 

General  Principles. — In  doing  this  class  of  operations  it  is 
wise  to  adhere  strictly  to  the  rules  applying  to  the  particular  vessel, 
as  in  this  way  only  will  the  possibility  of  missing  the  vessels  be 
avoided  by  those  unfamiliar  with  the  operation.  In  applying  a  liga- 
ture to  large  vessels  the  proximity  of  important  branches  should  be 
avoided,  as  otherwise  the  formation  of  a  secure  thrombus  may  be  seri- 
ously interfered  with.  Throughout  this  article  little  stress  is  laid  upon 
the  exact  length  of  the  incision,  because  it  is  believed  that  it  must 
vary  so  much  with  different  patients  that  exact  measurements  are  more 
misleading  than  otherwise,  and  that  the  incision  should  always  be 
large  enough  to  give  ample  room.  This  statement,  however,  does  not 
apply  to  the  opening  made  in  the  sheath  of  the  vessel,  which  should 
be  made  as  small  as  possible,  thereby  avoiding  damage  to  the  vasa 
vasorum,  by  which  the  coats  of  the  artery  are  nourished.  It  is  not 
necessary  to  separate  the  venae  comites  from  the  smaller  vessels ; 
troublesome  oozing  may  be  avoided  by  tying  them  with  the  artery  en 
masse.  In  this  same  connection,  less  stress  is  laid  upon  the  direction 
in  which  the  needle  is  passed  than  has  usually  been  done ;  but  when 
the  dissection  is  freely  made  and  the  needle  passed  by  sight  rather 
than  by  feeling,  the  danger  of  wounding  vessels  and  including  nerves 
in  the  ligature  is  much  diminished ;  and  the  use  of  a  Cleveland  needle 
is  advised,  as  being  more  convenient  and  easier  of  manipulation.  For 
vessels  of  moderate  size  catgut  is  satisfactory,  but  for  larger  vessels 
silk  is  a  safer  material. 

The  anatomy  of  the  supraclavicular  region  with  reference  to  the  innominate 
and  subclavian  arteries.  The  innominate  bifurcates  opposite  the  right  sternoclavicular 
articulation.  The  subclavian  artery  arches  upward,  so  that  its  highest  point  is  '/£  to  I  inch 
above  the  clavicle,  and  ends  underneath  the  middle  of  that  bone.  The  subclavian  vein 
lies  behind  the  clavicle  on  a  lower  level  than  the  artery,  and  separated  from  it  by  the  sca- 
lenus anticus  muscle.  The  vein  is  held  to  the  clavicle  by  a  portion  of  the  deep  cervical 
fascia.  The  phrenic  nerve  crosses  the  scalenus  anticus  obliquely  and  passes  downward 
between  it  and  the  subclavian  vein.  The  relations  of  the  first  part  of  the  artery  vary  on 
the  two  sides.     On  the  right,  the  artery  is   in   contact  with  the   pleura  below  and  behind. 


THE  LIGATURE    OF  ARTERIES. 


317 


The  pneumogastric  nerve  passes  in  front,  and  its  recurrent  branch,  turning  below  the  artery, 
runs  upward  behind.  The  internal  jugular  and  subclavian  veins  unite  in  front  of  this  por- 
tion to  form  the  right  innominate  vein,  which  passes  downward  in  front  of  the  outer  side 
of  the  subclavian  and  innominate  arteries.  The  left  innominate  vein  is  not  in  relation  to 
its  artery,  but  crosses  the  origin  of  the  left  common  carotid  and  unites  with  its  fellow  in 
front  of  the  innominate  artery.  The  left  subclavian  is  an  inch  longer  than  the  right  and 
lies  at  a  deeper  level  ;  its  outer  side  is  in  contact  with  the  pleura.  Behind  and  internally 
lie  the  esophagus,  recurrent  laryngeal  nerve,  and  trachea.  The  thoracic  duct,  at  first  on 
the  inner  side,  soon  arches  outward  and  forward,  behind  the  internal  jugular  vein,  to  join  the 
subclavian  at  their  angle  of  union. 

The  second  and  third  portions  are  similar  on  the  two  sides.  The  third  part  of  the  artery 
has  rarely  more  than  one  branch,  is  most  superficial,  and  is  therefore  the  portion  ligatured  by 
election.  It  lies  in  a  triangle  bounded  below  by  the  clavicle,  on  the  upper  and  outer  side 
by  the  posterior  belly  of  the  omohyoid  muscle,  on  the  inner  side  by  the  outer  border  of  the 
sternomastoid.  The  inner  cord  of  the  brachial  plexus  is  behind  the  artery,  where  it  rests 
on  the  first  rib.  The  subclavian  vein  is  below  and  anterior.  At  the  lower  outer  margin  of 
the  sternomastoid  the  external  jugular  joins  the  latter  vein.  The  supraclavicular  fascia  is 
crossed  superficially  from  above  downward  and  outward  by  the  supraclavicular  nerves. 
Under  the  cervical  fascia  the  field  of  operation  is  crossed  by  several  large  veins,  namely,  the 
transverse  cervical,  the  suprascapular,  the  posterior  external  jugular,  and  the  inferior  thyroid. 
Troublesome  hemorrhage  may  arise  from  these  unless  they  are  tied  before  division. 

I/igature  of  the  Innominate  Artery  (Fig.  71). — Ligature  of 
this  artery  is  rightly  regarded  as  one  of  the  most  difficult  and  danger- 


V.jugul.  int. 

Portio  clavicul. 
A.  carotis 
A.  subclavia 


1 


Af.  sternohyoid. 


Trachea. 
Jii£     Art.  anonyma. 


Mm.  sternothyroid. 


Portio  sternalis  M.  sternocl.-mast. 


Fig.  71. — Topography  of  the  truncus  anonymus  in  the  fossa  jugularis  (after  Loebker). 


ous  operations.  Twenty-nine  authentic  cases  were  reported  by  Burrell 
in  1895.  Of  these,  1  case  lived  ten  years  after  operation,  and  1,  one 
hundred  and  four  days ;  all  the  others  died  within  two  months,  from 
shock,  sepsis,  or  secondary  hemorrhage  ;  though  in  Burrell's  case,  which 
lived  one  hundred  and  four  days,  death  may  be  properly  attributed  to 
coexisting  cardiac  disease.  With  our  improved  technic,  the  mortality 
from  sepsis  and  attendant  secondary  hemorrhage  can  surely  be  dimin- 
ished. In  such  a  formidable  procedure,  it  seems  wise  to  disregard  soft 
parts,  and  even  bone,  and  the  following  operation  is  therefore  advo- 
cated : 


3l8  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

By  Resection  of  a  Portion  of  the  Sternum. — An  incision  is  made 
from  the  level  of  the  cricoid  cartilage  along  the  anterior  border  of  the 
sternomastoid  down  the  middle  of  the  sternum  to  the  gladiolus.  The 
lower  attachments  of  the  right  sternomastoid,  sternohyoid,  and  sterno- 
thyroid muscles  are  divided  close  to  the  Lone  and  allowed  to  retract. 
A  spatula  is  placed  between  the  sternum  and  the  large  veins.  The 
upper  outer  part  of  the  manubrium  with  the  sternoclavicular  articula- 
tion and  insertion  of  the  first  rib  should  then  be  removed  with  a  chisel 
or  rongeur  forceps.  The  large  inferior  thyroid  veins  are  found  and  di- 
vided between  ligatures.  The  innominate  artery  is  thus  freely  exposed, 
and  the  surrounding  structures  may  be  identified  by  sight  as  well  as 
touch.  With  the  finger  or  a  blunt  dissector  the  areolar  tissue  is  gently 
separated  from  the  vessel.  In  front. lies  the  junction  of  the  left  and 
right  innominate  veins,  dilating  and  contracting  with  respiration.  To 
the  outer  side  are  found  the  phrenic  and  pneumogastric  nerves,  with 
the  pleura.  Behind,  and  on  the  inner  side,  the  artery  rests  on  the 
trachea.  Avoiding  all  these  structures,  two  large  silk  ligatures  are 
passed  about  the  vessel,  \  inch  apart.  These  are  tightened  gently  and 
firmly  until  pulsation  ceases  in  the  distal  portion.  In  aneurysm,  the 
common  carotid  and  vertebral  arteries  should  also  be  ligatured,  to  pre- 
vent collateral  circulation  in  the  sac. 

ligature  of  the  Subclavian  Artery. — The  incision  for  ligature 
of  the  first  portion  of  the  left  subclavian  is  similar  to  that  for  the 
innominate  artery,  though,  of  course,  on  the  opposite  side.  The 
muscles  and  deep  cervical  fascia  are  divided  in  the  same  manner.  No 
bone  will  require  removal  unless  the  vessel  is  to  be  tied  near  the  arch, 
where  it  is  situated  even  deeper  than  the  innominate  artery.  The 
internal  jugular  and  left  innominate  veins  are  retracted,  respectively, 
outward  and  downward.  The  thoracic  duct  offers  the  chief  difficulty. 
Search  should  be  made  for  the  main  trunk  to  the  inner  side  of  the 
ascending  subclavian.  It  arches  at  a  higher  level  than  the  artery,  and 
frequently  ends  by  two  or  three  branches.  When  the  ligature  is  passed 
from  within  outward,  the  pneumogastric  nerve  and  duct  should  be 
pushed  inward  and  the  phrenic  nerve  carefully  defined  on  the  outer 
side. 

The  Right  Subclavian  in  its  First  Portion. — A  similar  incision  is 
made,  ending,  however,  an  inch  below  the  sternoclavicular  joint.  No 
bone  need  be  removed.  The  sternomastoid  is  divided  and  retracted 
outward  with  the  internal  jugular  vein.  The  phrenic  nerve  is  found 
along  the  inner  border  of  the  scalenus  anticus  ;  the  pneumogastric 
nerve  lies  in  front  of  the  vessel.  The  numerous  arterial  branches 
must  be  isolated  and  pushed  aside,  and  the  ligature  passed  by  sight 
below  them.  This  is  a  very  dangerous  procedure,  there  having  been 
only  3  successful  cases  reported.1 

The  Second  Portion — The  incision  and  steps  are  the  same  as  for 
the  ligation  of  the  third  portion,  next  to  be  described.  Avoiding  the 
phrenic  nerve,  which  is  held  to  the  inner  side,  the  scalenus  anticus  is 
cautiously  divided  by  a  transverse  incision  and  allowed  to  retract.  The 
artery  lies  immediately  behind  it  with  one  or  more  branches.  The 
ligature  is  passed  from  before  backward. 

1  Halsted,  1892  ;  B.  F.  Curtis,  1897  ;  Allingham,  1S99. 


THE   LIGATURE    OF  ARTERIES. 


319 


The  Third  Portion  (Fig.  72). — This  part  of  the  artery  is  relatively 
easy  of  access,  and  is  ligatured  for  hemorrhage,  aneurysm,  or  as  a  pre- 
liminary to  amputation  of  the  upper  extremity.  The  artery  has  similar 
relations  on  both  sides  of  the  body.  Having  previously  pulled  the 
skin  over  the  clavicle  firmly  downward,  a  4-inch  incision  is  begun,  an 
inch  from  the  sternoclavicular  joint,  and  carried  along  the  clavicle 
down  to  the  bone.  The  parts  are  allowed  to  retract,  and  the  deep 
fascia  is  then  divided.  The  external  jugular  vein  at  the  posterior 
border  of  the  sternomastoid  is  easily  cut  between  two  ligatures.  The 
shoulder  must  now  be  pulled  down  as  far  as  possible.  In  muscular 
subjects  the  space  between  the  clavicular  attachments  of  the  trapezius 
and  sternomastoid  is  often  narrow,  and  part  of  these  muscles  may 
require  division.     The  supraclavicular  fat  is  gently  separated  from  the 


V.  supraclav. 


M.  omohyoideus 

Fascia  super/. 


Fig.  72. 


M.  sternocleidomast. 

V.  jug  11 1,  ext. 
M.  scalenus  ant. 
A.  suhclavia. 
PI.  brachialis. 


-Topography  of  the  subclavian  artery  above  the  clavicle,  outside  the  scalenus  amicus 
muscle  (after  Loebker). 


underlying  structure  and  retracted  upward  and  inward.  The  operator, 
standing  at  the  patient's  head,  next  defines  the  insertion  of  the  scalenus 
anticus  into  the  tubercle  of  the  first  rib.  This  is  best  done  by  inserting 
the  forefinger  deeply  into  the  wound,  using  the  right  hand  in  right 
incisions,  and  the  left  in  left  incisions.  The  artery  will  be  felt  pulsating 
behind  and  to  the  outer  side  of  the  tubercle.  The  vein  lies  in  front, 
and  is  rarely  seen.  Posterior  to  the  vessel  lie  the  inner  cords  of  the 
brachial  plexus.  In  this  and  similar  operations  in  the  neck,  the  smaller 
veins  which  are  encountered  should  be  divided  between  two  ligatures  ; 
arterial  twigs  should  be  similarly  treated.  By  such  careful  technic 
staining  of  the  areolar  tissue  with  blood  is  avoided  and  the  dissection 
far  more  clearly  made.  With  the  artery  in  plain  sight,  the  sheath  is 
carefully  incised  and  the  ligature  passed  in  either  direction,  preferably 
from  the  vein. 

I/igature  of  the  Superior  Thyroid  Artery  (Fig.  73). — This 
artery  arises  from  the  external  carotid  at  the  upper  edge  of  the  thyroid 


320 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


cartilage,  and  passes  inward  and  downward,  sending  branches  to  the 
thyroid  muscles  and  gland.  The  superior  laryngeal  nerve  is  just  above 
and  to  its  inner  side.  The  only  indications  for  tying  this  vessel  are 
vascular  enlargements  of  the  thyroid  gland,  and  as  a  preliminary  to 
thyroidectomy. 

Operation. — An  incision,  3  inches  long,  is  made  along  the  inner 
border  of  the  sternomastoid,  with  its  center  opposite  the  upper  part 
of  the  tumor.  The  skin  and  deep  fascia  are  divided,  and  the  sterno- 
mastoid muscle  drawn  to  the  outer  side.  Search  is  made  at  the  upper 
inner  aspect  of  the  lateral  lobe  of  the  thyroid,  and  the  anterior  branch 


,- 


N.  hypoglossus. 

A.  lingualis. 

V.  facialis  commun. 
A.  caro/is  ext. 
A.  thyroidea  sup. 
Ram.  descend. 

N.  hypogl. 
N.  vagus. 

A.  carotis  communis. 
M.  omohyoideus. 

M.  stemothyroideus. 

\f.  stentohyoideus. 

1/.  sternocleidomastoid. 


Fig.  73, 


- 


-Topography   of   the  carotid  artery  from   the  cricoid   cartilage  to  the  hyoid  bone 
(after  Loebker). 


of  the  artery  easily  found.  This  is  ligatured,  or  the  artery  followed 
higher  up  in  the  neck  and  there  tied. 

ligature  of  the  Inferior  Thyroid  Artery. — This  branch  arises 
from  the  thyroid  axis,  and  passes  upward  to  the  level  of  the  cricoid 
cartilage,  where  it  bends  sharply  inward  and  divides  into  two  branches 
behind  the  lower  part  of  the  lateral  lobe  of  the  gland.  The  recurrent 
laryngeal  nerve  passes  upward  in  the  groove  between  the  trachea  and 
esophagus,  and  usually  behind  the  terminal  branches  of  the  artery. 
The  vessel  rests  on  the  longus  colli  muscle  close  to  the  vertebral 
column. 

Operation. — A  3-inch  incision  is  made,  opposite  the  cricoid  cartilage, 
along  the  anterior  border  of  the  sternomastoid.  This  muscle  is  re- 
tracted to  the  outer  side  with  the  common  sheath  of  the  great  vessels, 
while  the  larynx  and  thyroid  gland  are  pulled  inward.  The  inferior 
thyroid  artery  can  always  be  recognized  from  its  horizontal  direction. 
Half  an  inch  below  the  carotid  tubercle,  the  sympathetic   cord  crosses 


THE   LIGATURE    OF  ARTERIES. 


321 


it  at  right  angles,  and  should  be  pushed  to  the  outer  side.  The  recur- 
rent laryngeal  nerve,  lying  near,  can  also  be  recognized  by  its  vertical 
direction,  nearer  the  median  line.  The  ligature  is  passed  from  below 
upward,  away  from  the  inferior  thyroid  veins,  and  tied. 

I/igature  of  the  Vertebral  Artery. — This  artery  arises  from  the 
subclavian  ciose  to  the  inner  border  of  the  scalenus  anticus.  In  the 
groove  between  this  muscle  and  the  longus  colli  it  runs  upward  to  the 
transverse  process  of  the  sixth  cervical  vertebra. 

Operation. — The  operation  is  the  same  as  that  for  ligature  of  the 
inferior  thyroid,  but  more  difficult,  as  the  vertebral  artery  lies  deeper 
under  the  prevertebral  fascia.  This  fascia  is  vertically  incised  \  inch 
below  the  carotid  tubercle.  The  artery  is  here  ligatured  just  above  the 
bend  of  the  inferior  thyroid,  which  is  pushed  downward.  The  verte- 
bral vein  is  best  ligatured  with  the  artery. 

I/igature  of  the  Axillary  Artery  (Fig.  74). — This  vessel  extends 
from  the  lower  border  of  the  first  rib  to  the  lower  margin  of  the  teres 


M.  deltoideus. 
A.  axillaris. 


I '.  cephal. 

M.  coracobrachial. 


PL  brachialis, 


A.  subclavia, 


V.  subclavia. 


M.  pect.  min 


M.  pect.  maj 


Fig.  74. — Topography  of  the  subclavian  and  axillary  arteries  on  the  front  chest-wall  (after 

Loebker). 


major.  If  the  arm  is  abducted  to  a  right  angle,  the  artery  lies  under  a 
line  drawn  from  the  middle  of  the  clavicle  to  the  middle  of  the  bend 
of  the  elbow.  It  is  divided  into  three  portions  by  the  pectoralis  minor. 
Above  this  muscle  the  costocoracoid  membrane  sends  an  expansion  to 
the  axillary  vein,  which  lies  internal  and  anterior  to  the  artery.  On  the 
outer  side  run  the  cords  of  the  brachial  plexus.  The  cephalic  vein 
passes  upward  along  the  inner  border  of  the  deltoid,  and  between  it 
and  the  pectoralis  major ;  having  pierced  the  costocoracoid  membrane, 
it  empties  into  the  axillary  vein. 

Operation. — A  4-inch  incision  should  be  made  over  the  interspace 
between  the  deltoid  and  pectoralis  major,  which  muscles  should  then 
be  widely  retracted.     The  cephalic  vein,  previously  defined,  is  left  in 
21 


322 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


the  outer  margin  of  the  wound.  The  costocoracoid  fascia  is  incised 
with  care,  and  the  axillary  vein  found  and  pulled  inward.  Deeply 
placed  and  slightly  to  the  outer  side  of  it  lies  the  artery.  The  ligature 
is  passed  away  from  the  adjacent  nerve-cords.  This  operation  is  more 
bloody  and  difficult  than  ligature  of  the  third  part  of  the  subclavian. 

Ligature  in  the  Axilla. — An  incision  3  inches  long  is  made  at  the 
junction  of  the  anterior  and  middle  thirds  of  the  axilla,  along  the  pos- 
terior border  of  the  coracobrachialis  muscle.  The  deep  fascia  is 
incised  and  the  two  lips  of  the  wound  evenly  retracted.  The  vein  is 
below  and  slightly  overlaps  the  artery.     Above  is  the  median  nerve ; 


JV.  medianus. 
A.  axillaris. 
|T  N.  ulnaris. 

A7,  radialis. 


V.  axillaris. 


Fig.  75. — Topography  of  the  axillary  artery  (after  Loebker). 


below  are  the  internal  cutaneous  and  ulnar  nerves.  These  structures 
should  be  retracted,  and  the  artery  isolated  and  tied. 

ligature  of  the  Brachial  Artery. — The  brachial  artery  extends 
from  the  junction  of  the  anterior  and  middle  thirds  of  the  axilla  to  the 
inner  side  of  the  biceps  tendon  at  the  middle  point  of  the  bend  of  the 
elbow.  Opposite  the  neck  of  the  radius  it  divides  into  the  ulnar  and 
radial  arteries  ;  the  median  nerve  follows  the  vessel  closely.  At  first, 
the  median  nerve  lies  to  the  upper  and  outer  side  of  the  artery,  which 
it  crosses,  usually  in  front,  about  the  middle  of  the  arm,  and  continues 
its  course  along  the  inner  side.  The  artery  lies  in  the  groove  between 
the  biceps  and  triceps  muscles.  The  brachial  venae  comites  are  irregu- 
lar in  size:  just  above  the  middle  of  the  arm  the  basilic  vein  pierces 
the  deep  fascia,  to   unite  with   them   to  form  the   axillary  vein. 

Operation  at  the  Middle  of  the  Arm. — An  incision  is  made  over 
the  line  of  the  artery  and  carried  through  the  deep  fascia.  The  basilic 
vein  should  be  made  tense  and  avoided ;  the  biceps  muscle  is  disclosed 
and  drawn  outward ;  the  sheath  surrounding  the  artery,  veins,  and 
nerves  is   carefully  incised  ;   the  artery  separated  and  ligated.     Occa- 


THE   LIGATURE    OF  ARTERIES. 


323 


sional  high  division  of  the  brachial  artery  should  always  be  borne  in 
mind. 

Ligature  at  the  Bend  of  the  Elbow. — An  oblique  incision  is  made 
along  the  inner  border  of  the  biceps  tendon,  ending  at  the  bicipital 
fascia.  By  this  incision  superficial  veins  may  usually  be  avoided.  The 
artery  is  exposed,  lying  between  the  bicipital  tendon  on  the  outer  side 
and  the  median  nerve  on  the  inner  side,  and  resting  on  the  brachialis 
anticus  muscle.     The  venae   comites   may  be  included  in  the  ligature. 

Ligature  of  the  Radial  Artery.— This  artery  runs  from  the 
bifurcation  of  the  brachial  to  the  inner  side  of  the  styloid  process  of 


N.  medianus. 

V.  brachialis. 

A.  brachialis. 

M.  biceps. 

Lacert.  fibr. 

V.  mediana  basilica. 

M.  supinator  longus. 

N.  radialis, 

M.  pronator  teres. 

A.  radialis. 


FlG.  76. — Topography  of  the  brachial  and  radial  arteries  (right  arm)  (after  Loebker). 


the  radius.  The  artery  is  covered  in  its  upper  third  by  the  belly  of  the 
supinator  longus,  then  runs  superficially  along  its  inner  border.  The 
radial  nerve  is  in  relation  to  the  vessel  only  in  the  middle  third,  and 
lies  to  the  radial  side. 

Ligature  in  the  Upper  Third. — An  incision,  beginning  2  inches  be- 
low the  bend  of  the  elbow,  is  made  over  the  line  of  the  artery,  and 
is  carried  through  the  deep  fascia.  The  supinator  longus  is  raised  and 
drawn  to  the  outer  side.  The  pronator  radii  teres,  of  which  the  oblique 
fibers  are  easily  recognized,  is  pulled  to  the  inner  side.  The  artery, 
with  its  venae  comites,  is  isolated  and  tied. 

Ligature  in  the  Lower  Third. — An  incision  2  inches  long  is  made 
upward  in  the  line  of  the  artery,  beginning  an  inch  above  the  tip  of  the 


3  24 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


styloid  process.  The  artery  is  found  immediately  beneath  the  deep 
fascia.  On  the  ulnar  side  is  the  tendon  of  the  flexor  carpi  radialis.  The 
radial  nerve  is  not  seen.     The  artery  is  isolated  and  tied. 

Ligature  of  the  Ulnar  Artery. — The  line  for  incision  in  tying 
this  artery  runs  from  the  internal  condyle  to  the  radial  side  of  the 
pisiform  bone.  In  the  lower  two-thirds  of  the  forearm  the  artery  lies 
directly  under  this  line.  In  the  upper  third  the  vessel  is  covered  by 
the  superficial  muscles  arising  from  the  internal  condyle,  and  is  situated 
under  a  slightly  curved  line,  with  the  convexity  inward,  drawn  from 
the  upper  border  of  the  middle  third  to  the  point  of  bifurcation.     The 


A.  ulnaris 
M.JIex.  carpiuln. 

N.  ulnarh 
M.flcx.  dig.  sub  I 


X.  radialis 
A.   radialis. 
M.  s ii pi 11.  long. 
M.  fl.  carpi  rad. 


FlG.  77. — Topography  of  the  radial  and  ulnar  arteries  (after  Loebker). 


ulnar  nerve  joins  the  artery  above  its  middle  and  runs  to  the  wrist  on 
its  ulnar  side. 

The  Junction  of  the  Upper  and  Middle  Thirds  of  the  Arm. — An 

incision  4  inches  long,  with  its  center  at  the  above  point,  if  made  on 
the  line,  will  disclose  the  intermuscular  space  between  the  flexor  carpi 
ulnaris  and  sublimis  digitorum  muscles.  This  septum  will  be  marked 
as  a  white  or  yellow  line  under  the  deep  fascia.  Should  any  difficulty 
be  met,  a  superficial  transverse  incision  through  the  muscles  will  be  of 
great  help.  On  carefully  separating  these  two  muscles  and  pulling  the 
superficial  flexor  inward,  the  ulnar  nerve  comes  first  into  view,  lying 
on  the  deep  flexor ;  a  little  outward,  but  in  the  same  plane,  is  found  the 
ulnar  artery.  A  needle  is  passed  from  the  nerve  about  the  veins  and 
artery. 

In  the  Lower  Third. — An  incision  through  the  deep  fascia  is  made 
just  to  the  radial  side  of  the  tendon  of  the  flexor  carpi  ulnaris.  The 
muscular  belly  extends  almost  to  the  wrist,  and  should  be  retracted  to 


THE   LIGATURE    OF  ARTERIES.  325 

the  ulnar  side.     The  ligature  is  passed  from  the  nerve  which  lies  on  the 
ulnar  side. 

ligature  of  the  Common  Carotid. — In  operations  in  the  neck 
the  position  of  the  head  is  most  important.  The  face  should  be  turned 
from  the  side  to  be  operated  upon,  the  shoulder  depressed,  and  a  firm 
pillow  placed  behind  the  extended  neck  ;  later  the  head  may  be  flexed 
to  relax  the  muscles.  The  line  of  the  carotid  artery  runs  from  the' 
sternoclavicular  articulation  to  a  point  midway  between  the  angle  of 
the  jaw  and  the  mastoid  process.  The  carotid  divides  opposite  the 
upper  border  of  the  thyroid  cartilage.  Here  the  external  carotid  is 
anterior,  the  internal  posterior.  This  relation  soon  changes,  the  exter- 
nal carotid  lying  to  the  outer  side  and  posterior  to  the  internal  carotid. 
The  length  of  the  right  common  carotid  is  usually  3^  to  4  inches,  the 
left  an  inch  more.  The  internal  jugular  vein  emerges  from  the  skull 
behind  the  internal  carotid ;  it  soon  passes  to  the  outer  side  of  the 
artery,  greatly  increased  in  size  by  the  addition  of  the  temporofacial 
veins  at  the  level  of  the  hyoid  bone,  and  runs  down  the  neck  on  the 
outer  side  of  the  common  carotid  artery,  which  it  overlaps.  The  pneu- 
mogastric  nerve  lies  behind  and  between  the  common  carotid  and 
internal  jugular  vein,  and  is  enclosed  in  a  separate  compartment  of  the 
common  sheath.  The  hypoglossal  nerve  curves  inward  about  the 
occipital  artery  at  its  origin,  sending  off  the  descendens  hypoglossi 
nerve,  which  runs  downward  over  the  common  sheath.  As  the  sterno- 
mastoid  muscle  passes  to  its  insertion,  it  crosses  the  common  carotid 
obliquely,  so  that  the  lower  portion  of  the  artery  comes  to  lie  deeply 
near  its  posterior  border.  The  omohyoid  muscle  crosses  the  artery  at 
the  level  of  the  cricoid  cartilage.  The  point  of  election  is  above  the 
tendon  of  this  muscle.  As  ligature  of  the  common  carotid  will  not 
completely  control  hemorrhage  from  the  external  carotid  branches, 
owing  to  the  free  anastomosis,  and  as  brain-symptoms  follow  ligature 
of  the  common  carotid  in  about  20  per  cent,  of  all  cases,  this  opera- 
tion should  never  be  done  when  ligature  of  the  external  carotid  alone 
will  suffice. 

Operation. — A  3-inch  incision  downward  from  the  cricoid  cartilage 
is  made  along  the  anterior  border  of  the  sternomastoid.  The  skin, 
subcutaneous  tissue,  platysma,  and  deep  cervical  fascia  are  divided. 
The  sternomastoid  is  retracted  to  the  outer  side.  Above  the  omohyoid 
the  artery  is  quite  superficial.  The  common  sheath  is  carefully  opened 
on  its  inner  side,  to  avoid  the  jugular  vein.  The  artery  is  isolated  with 
a  blunt  dissector.  The  needle  is  passed  from  the  vein,  avoiding  the 
pneumogastric  nerve  behind.  Below  the  omohyoid  the  artery  lies  deep 
in  the  neck,  under  the  sternomastoid.  When  an  aneurysm  exists  in 
the  upper  part  of  the  artery,  this  muscle  may  require  division  before 
the  ligature  can  be  properly  applied. 

Ligature  of  the  Internal  and  External  Carotids  at  their 
Origins. — An  incision  of  3  inches  is  made  along  the  anterior  border  of 
the  sternocleidomastoid,  from  the  angle  of  the  jaw  downward  through 
the  deep  fascia.  The  external  jugular  vein  should  be  divided  between 
two  ligatures,  and  the  muscle  retracted  outward  as  before.  The 
temporofacial  vein,  as  it  unites  with  the  internal  jugular,  should  be 
pulled  upward  and  outward.     By  its  branches  the  external  carotid  may 


3-6 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


be  distinguished  from  the  single  trunk  of  the  internal  carotid  lying 
behind.  The  superior  laryngeal  nerve  passes  along  the  inner  side  of 
the  internal  jugular  to  the  larynx.  The  pneumogastric  nerve  must  be 
clearly  seen.  The  ligature  is  passed  from  without  inward  about  either 
artery. 

ligature  of  the  lingual  Artery. — The  lingual  artery,  a  branch 
of  the  external  carotid,  is  given  off  at  about  the  level  of  the  greater 
cornu  of  the  hyoid  bone,  where  it  is  deeply  placed.  It  passes  forward 
beneath  the  stylohyoid  and  posterior  belly  of  the  digastric,  and  enters 
the  submaxillary  triangle,  which  is  bounded  by  the  anterior  and  pos- 
terior bellies  of  the  digastric  and  the  ramus  of  the  jaw.  Shortly  after 
entering  this  triangle  the  vessel  passes  behind  the  hyoglossus  muscle, 
by  which  it  is  covered  throughout  the  rest  of  its  course.     The  hypo- 


M.    stylohyoid   et    bi- 
venter. 

A.  maxill.  ext. 


M.  hyoglossus. 

V.  lingualis. 

N.  hypoglossus. 

M.  mylohyoideus. 

M.  biventer. 

Fascia  colli  super/. 


WMif 


W)M[' 


Platysma. 

Os  hy aides. 

A.  lingualis. 

M.  sternocleidomast.- 

FIG.  78. — Topography  of  the  lingual  and  facial  arteries  (after  Loebker). 

glossal  nerve  also  crosses  the  submaxillary  triangle  in  a  direction 
parallel  to  the  jaw  and  superficial  to  the  hyoglossus  muscle,  which  thus 
separates  the  nerve  from  the  artery.  The  triangle  formed  by  the  two 
bellies  of  the  digastric  below  and  the  hypoglossal  nerve  above  is  the 
most  convenient  situation  in  which  to  secure  the  lingual  artery,  and  is 
readily  found. 

Operation. — A  curved  incision  is  made,  starting  at  the  angle  of  the 
jaw  and  descending  to  the  level  of  the  hyoid  bone,  and  then  up  again 
to  a  point  about  1  inch  to  one  side  of  the  symphysis  of  the  jaw.  This 
cut  is  deepened  so  as  to  divide  the  skin,  platysma,  and  the  deep  fascia 
attached  to  the  hyoid  bone.  The  flap  thus  formed  is  turned  up,  carry- 
ing with  it  the  submaxillary  gland,  and  the  digastric  muscle  and  hypo- 
glossal nerve  come  into  view.  The  mylohyoid  muscle  may  encroach 
considerably  upon  the  triangle,  and  its  posterior  fibers  should  be  divided 
if  necessary.  The  field  having  been  fully  exposed,  the  hyoglossus 
muscle  is  divided  close  to  the  hyoid  bone  and  turned  upward,  when 


THE   LIGATURE    OF  ARTERIES.  327 

the  lingual  artery  will  be  seen  running  nearly  parallel  to  the  course  of 
the  hypoglossal  nerve.     There  is  no  vein  in  close  relation  to  the  artery. 

I/igattire  of  the  Facial  Artery. — The  facial  artery  leaves  the 
carotid  generally  in  close  relation  to  the  lingual  artery  and  passes 
beneath  the  hyoid  muscle  to  the  deep  surface  of  the  submaxillary  gland, 
under  cover  of  which  it  runs  until  it  reaches  the  masseter,  when  it 
turns  abruptly  upward  along  its  anterior  border,  where  the  pulsation 
can  be  felt.  The  vein  lies  posterior  to  the  artery  and  crosses  the  sub- 
maxillary gland  superficially. 

Operation. — The  vessel  is  best  exposed  by  an  incision  parallel  to  the 
ramus  of  the  jaw,  with  its  center  at  the  anterior  border  of  the  masseter 
muscle.  In  this  way  the  vessel  can  be  found  without  difficulty  ;  the 
small  branches  of  the  facial  nerve  are  not  injured,  and  the  scar  is  better 
placed.  The  ligature  is  generally  passed  from  behind  forward,  but  the 
vein  is  not  always  very  close  to  the  artery. 

ligature  of  the  Occipital  Artery. — The  occasions  on  which 
this  vessel  will  be  tied  must  be  exceedingly  rare,  as  in  cases  of  cirsoid 
aneurysm  of  the  scalp  the  afferent  and  efferent  vessels  will  be  tied  as 
they  appear,  without  regard  to  their  position.  The  vessel  ma}'  be 
found  by  making  an  incision  from  the  tip  of  the  mastoid  process  back- 
ward and  slightly  upward  for  about  2  inches.  The  aponeurosis  of  the 
steimomastoid  and  the  insertion  of  the  splenius  must  be  freely  divided, 
when  the  pulsation  of  the  vessel  can  be  felt. 

Iyigature  of  the  Temporal  Artery. — The  temporal  artery  is  the 
linear  continuation  of  the  external  carotid,  which  divides  into  its  ter- 
minal branches,  the  temporal  and  internal  maxillary,  at  about  the  level 
of  the  neck  of  the  lower  jaw.  The  temporal  artery  is  at  first  deeply 
placed  in  the  substance  of  the  parotid  gland  ;  but  at  about  the  level  of 
the  external  auditory  meatus  it  becomes  superficial,  running  upward  in 
front  of  the  ear  over  the  root  of  the  zygoma,  and  divides  into  its  ter- 
minal branches  at  a  variable  distance  above  that  level.  The  temporal 
vein  and  the  auriculotemporal  nerve  lie  between  it  and  the  ear.  It  is 
best  exposed  by  a  vertical  incision  1  inch  in  length,  a  finger's  breadth 
in  front  of  the  ear,  starting  at  the  level  of  the  zygoma  and  running 
upward.  This  will  avoid  danger  of  injuring  the  branches  of  the  facial 
nerve,  which  are  below  the  zygoma  at  this  point. 

ligature  of  the  Abdominal  Aorta. — As  far  as  we  are  aware, 
the  abdominal  aorta  has  never  been  successfully  tied,  though  several 
attempts  have  been  made.  The  technic  of  the  operation  presents  no 
difficulties.  The  incision  should  be  made  through  the  left  rectus  mus- 
cle, about  1  inch  from  the  median  line,  with  its  center  at  the  level  of 
the  umbilicus.  The  peritoneal  cavity  should  be  freely  opened,  and  the 
intestines  walled  back  with  gauze.  The  position  of  the  vessel  can  be 
told  by  feeling  the  pulsations  with  the  finger ;  the  posterior  parietal 
peritoneum  is  incised,  and  the  ligature  passed  from  the  right  side,  to 
avoid  the  vena  cava. 

I/igature  of  the  Common  Iliac  Artery. — The  position  of  the 
common  iliac  artery  is  indicated  by  a  line  drawn  from  the  left  side  of 
the  umbilicus  to  the  center  of  a  line  connecting  the  anterior  superior 
spine  of  the  ilium  with  the  symphysis  pubis.  The  vessel  varies  in 
length  from  \\  to  3  inches,  and  extends  from  the  fourth  lumbar  verte- 


328  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

bra  to  the  sacro-iliac  synchondrosis,  where  it  divides  into  the  external 
and  internal  iliacs.  The  relations  of  the  vessels  to  veins  differ  some- 
what on  the  two  sides,  the  left  being  in  relation  only  with  the  left 
common  iliac  vein,  while  the  right  has  the  right  common  iliac  vein 
behind  its  lower  part,  the  left  common  iliac  vein  behind  it  above  the 
middle,  while  the  lower  end  of  the  vena  cava  lies  behind  its  upper  end. 
Both  vessels  are  in  the  same  relation  to  the  ureters,  which  cross  at  or 
near  the  bifurcation. 

After  ligature  of  the  common  iliac  the  collateral  circulation  is  car- 
ried on  through  the  anastomosis  of  the  internal  mammary  with  the 
deep  epigastric,  of  the  circumflex  iliac  with  the  lumbar  arteries,  and  of 
the  visceral  branches  of  the  internal  iliac  with  those  of  the  other  side. 
The  older  writers  laid  great  stress  on  the  extraperitoneal  method  of 
tying  the  common  iliac,  but  we  do  not  believe  that  the  method  was 
chosen  for  any  reason  other  than  the  fear  of  opening  the  peritoneal 
cavity — a  procedure  that  is  fraught  with  but  little  danger  to-day.  The 
extraperitoneal  method  necessarily  results  in  damage  to  the  retroperi- 
toneal adipose  tissue,  which  we  believe  to  be  far  more  liable  to  infection 
than  the  peritoneum,  and  can  hardly  avoid  some  damage  to  the  lumbar 
vessels  and  muscular  branches  which  play  an  important  part  in  the  col- 
lateral circulation.  The  choice  of  incision  lies  between  that  in  the 
median  line  and  that  through  the  rectus  muscle,  and  the  question  must 
be  decided  by  the  preference  of  the  individual  operator.  In  either  case, 
the  incision  should  start  at  about  the  level  of  the  umbilicus,  and  be 
continued  downward  a  variable  distance  according  to  the  thickness  of 
the  abdominal  wall.  The  use  of  the  Trendelenburg  position  will  facili- 
tate exposure  of  the  field  by  removing  the  mass  of  small  intestine,  and 
the  vessel  will  be  readily  found  running  along  the  brim  of  the  pelvis. 
The  peritoneum  covering  the  vessel  may  be  incised  somewhat  to  the 
outside,  and  the  opening  thus  made  freely  enlarged  with  the  fingers. 
The  ureter  is  in  relation  only  with  the  lower  part  of  the  vessel,  and  need 
not  be  seen ;  but  its  position  will  be  generally  so  obvious  that  there  is 
little  danger  of  its  being  injured.  The  chief  difficulty  will  be  found  in 
separating  the  vessel  from  the  veins  ;  and  it  is  important  to  have  a  thor- 
oughly good  exposure  and  plenty  of  room.  After  the  ligature  is  tied, 
the  peritoneum  covering  the  vessel  should  be  closed  with  sutures,  and 
the  remainder  of  the  operation  completed  as  in  any  clean  laparotomy. 
It  will  probably  be  wise  to  close  the  wound  without  drainage. 

I/igature  of  the  Internal  Iliac. — The  internal  iliac  runs  down- 
ward and  forward  from  the  sacro-iliac  synchondrosis.  It  is  in  relation 
anteriorly  with  the  ureter  and  at  its  upper  part  with  the  external  iliac 
vein,  posteriorly  with  the  internal  iliac  vein  ;  it  rests  on  the  nerves  of 
the  sacral  plexus.  It  is  exposed  by  an  incision  similar  to  that  for  the 
common  iliac,  but,  owing  to  its  depth  and  to  the  fact  that  on  the  left  it 
is  partially  covered  by  the  rectum,- the  operation  is  somewhat  more 
difficult.  Ligature  of  this  artery  is  rarely  done  except  for  gluteal 
aneurysm ;  though  recently  it  has  been  advocated  for  uterine  fibroid 
and  for  hypertrophy  of  the  prostate. 

I/igature  of  the  External  Iliac. — The  older  operators  usually 
preferred  to  tie  the  external  iliac  in  place  of  the  common  femoral,  for 
fear  of  secondary  hemorrhage  ;  but  at  the  present  time  this  danger  has 


THE  LIGATURE    OF  ARTERIES. 


329 


decreased  so  much  that  the  choice  must  be  made  upon  other  grounds. 
The  close  proximity  of  large  branches  makes  ligature  of  the  common 
femoral  a  more  difficult  procedure,  though  the  collateral  circulation  is 
somewhat  less  good  after  the  latter  operation.  The  vessel  lies  in  the 
line  already  indicated  for  the  common  iliac,  and  has  no  branches  of 


M.  obliq.  ext.  abdom. 

Fascia  superf. 

M.  transv.  abdom. 

N.  cruralis. 


Fascia  iliaca. 


Peritoneum. 
Art.  iliaca  ext. 
V.  iliaca  ext. 


M.  iliacus.  ~Srr~ 

i 

M.  obhq.  int.  abdom.  XA 

M.  ileopsoas. 

N.  cruralis. 

A.femoralis. 

V.fcmoralis. 

Fascia  lat.-^f^ 


Fig.  79. — Topography  of  the  external  iliac  and  femoral  arteries  (after  Loebker). 

importance  except  near  its  termination,  where  it  gives  off  the  deep  cir- 
cumflex iliac  and  the  deep  epigastric.  The  vein  lies  at  first  below  and 
later  to  the  inner  side,  while  the  genital  branch  of  the  genitocrural 
nerve  lies  rather  on  its  outer  side.  Ligature  of  this  vessel  is  most 
commonly  done  prior  to  amputation  at  the  hip-joint  and  for  femoral 
aneurysm,  and  the  exact  position  of  the  vessel  is  most  readily  found 
by  feeling  the  pulsation. 


33°  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

The  extraperitoneal  method  is  that  most  commonly  used.  The 
patient  should  be  placed  in  the  dorsal  position,  with  hips  elevated  so 
as  to  hyperextend  the  thigh.  The  incision  is  made  I  inch  above  and 
parallel  to  Poupart's  ligament,  with  its  center  over  the  line  of  the 
vessel.  The  deep  epigastric  artery  crosses  the  line  of  this  incision,  and 
should  be  avoided,  as  it  forms  an  important  part  of  the  collateral  anas- 
tomosis. The  incision  is  carried  down  to  the  peritoneum,  which  is  then 
pushed  back,  exposing  the  vessel. 

ligature  of  the  Gluteal,  Sciatic,  and  Internal  Pudic  Arte- 
ries.— Ligature  of  these  arteries,  except  for  traumatic  aneurysm,  will 
rarely,  if  ever,  be  done.  In  cases  of  hemorrhage  following  wounds, 
the  bleeding  point  will  be  sought  and  secured  regardless  of  its  ana- 
tomical position. 

The  gluteal  artery  emerges  from  the  pelvis  above  the  pyriformis 
muscle,  which  is  the  guide  to  the  vessel,  and  will  be  found  at  the  mid- 
dle third  of  a  line  drawn  from  the  posterior  superior  spine  of  the  ilium 
to  the  top  of  the  great  trochanter.  The  incision  should  be  free,  and 
should  be  deepened  until  the  pyriformis   muscle  is  found. 

The  sciatic  artery  is  placed  below  the  pyriformis  muscle,  and  its 
course  is  indicated  by  a  line  drawn  from  the  posterior  superior  spine  of 
the  ilium  to  the  tuberosity  of  the  ischium.  The  incision  should  be 
made  over  the  center  of  this  line,  parallel  to  the  fibers  of  the  gluteus 
maxim  us. 

The  internal  pudic  artery  leaves  the  pelvis  by  the  same  opening  as 
the  sciatic  artery ;  but  it  immediately  re-enters,  and  then  runs  up  along 
the  ramus  of  the  pubes.  It  is  most  readily  secured  in  the  perineum  by 
an  incision  made  on  a  line  extending  from  the  symphysis  pubis  to  the 
inner  part  of  the  tuber  ischiae. 

ligature  of  the  Femoral  Artery. — The  importance  of  the 
femoral  artery  in  operative  surgery  is  not  altogether  an  historic  one, 
for  the  vessel  is  not  infrequently  wounded,  and  ligature  of  this  vessel  is 
at  the  present  time  the  most  prominent  method  of  treating  popliteal 
and  femoral  aneurysms. 

The  course  of  the  vessel  may  be  indicated  by  a  line  drawn  from  a 
point  midway  between  the  anterior  superior  spine  of  the  ilium  and  the 
symphysis  pubis  to  the  adductor  tubercle  of  the  femur.  For  the  pur- 
pose of  operation  the  vessel  may  be  divided  into  three  parts:  I.  The 
common  femoral,  that  part  extending  from  Poupart's  ligament  to  the 
point  of  origin  of  the  profunda  femoris,  a  distance  of  from  I  to  2 
inches.  2.  The  superficial  femoral,  that  part  extending  from  the  origin 
of  the  profunda  to  the  apex  of  Scarpa's  triangle.  3.  The  femoral  in 
Hunter's  canal. 

Ligature  of  Common  Femoral. — This  operation  is  somewhat  unsat- 
isfactory, owing  to  the  close  proximity  of  large  branches  and  to  the 
fact  that,  in  the  past,  secondary  hemorrhage  has  been  of  frequent  occur- 
rence. The  vessel  is  exposed  by  an  incision  starting  at  Poupart's  liga- 
ment and  extending  downward  3  to  4  inches  in  the  line  indicated 
above.  It  is  covered  only  by  the  skin,  superficial  fascia,  and  iliac  fascia, 
which  latter  should  be  cautiously  divided.  The  vein  lies  to  the  inner 
side,  and  is  included  in  a  compartment  of  the  same  sheath  as  the  artery. 
This   sheath  should  be  freely  opened,  the  artery  separated  from  the 


THE  LIGATURE    OF  ARTERIES. 


331 


vein,  and  the  needle  passed  from  within  outward,  keeping  close  to  the 
artery.  The  anterior  crural  nerve  lies  \  inch  to  the  outer  side,  and 
should  not  be  seen.  It  is  advisable  to  ascertain  the  location  of  the 
circumflex  and  profunda  arteries  before  the  ligature  is  tied. 

Ligature  of  Superficial  Femoral. — The  superficial  femoral  is 
readily  accessible,  being  covered  only  by  the  skin  and  superficial  fascia. 
The  thigh  should  be  flexed  and  abducted,  and  an  incision  made  with 
its  center  4  to  5  inches  below  Poupart's  ligament,  in  the  line  of  the 
vessel.  The  sartorius  muscle  is  directly  to  the  outer  side,  and  will 
be  recognized  by  the  oblique  direction  of  its  fibers,  and  drawn  out- 
ward, revealing  the  artery,  with  the  vein  to  the  inner  side  and  some- 
what behind.     The  needle  should  be  passed  from  within  outward. 

Ligature  in  Hunter's  Canal. — Hunter's  canal  occupies  the  middle 
third  of  the  thigh,  which  should  be  partially  flexed  and  abducted,  as 
in  the  previous  operation.  The  incision  is  made  a  finger's  breadth  to 
the  inner  side  of  the  line  of  the  vessel,  so  as  to  find  the  sartorius  mus- 
cle. This  is  drawn  inward,  exposing  the  aponeurotic  covering  of  the 
canal  between  the  adductors  and  the  vastus  internus,  in  which  the 
vessel  lies.  The  internal  saphenous  nerve  should  be  found  lying  upon 
the  anterior  surface  of  the  artery,  while  the  vein  lies  behind  and  some- 
what to  the  inner  side.  The  ligature  should  be  passed  from  within 
outward  and  upward,  to  avoid  the  vein,  care  being  taken  not  to  include 
the  nerve. 

ligature  of  the  Popliteal  Artery. — The  popliteal  artery  is 
most    readily  reached  in    the  middle  of  the  popliteal   space  midway 


M.  semimembranosus. 

A.  poplitea. 

M.  semitendinosus . 

M.  gastrocnemius  int. 


N.  peroneus. 

V.  poplitea. 
N.  comm.Jibul. 

M.  gastrocnem.  ext. 


Fig.  80. — Topography  of  the  popliteal  artery  (after  Loebker). 


between  the  condyles  of  the  femur.  It  lies  directly  upon  the  bone, 
with  the  vein  behind  it,  and  the  internal  popliteal  nerve  superficial  to 
the  vein  and  slightly  to  the  inner  side.  The  patient  should  be  placed 
on  his  face,  with  the  leg  extended,  and  a  free  incision  made  through 
the  skin,  \  inch  outside  of  the  middle  line,  to  avoid  the  internal  saphe- 


332 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


nous  vein.  The  nerve  can  be  felt  as  a  tense  cord,  and  drawn  to  one 
side,  when  the  vein  will  be  found  embedded  in  a  mass  of  adipose  tissue 
and' intimately  adherent  to  the  artery.  It  should  be  carefully  but 
completely  separated,  and  all  bleeding  controlled.  If  the  dissection 
has  been  efficiently  done,  the  ligature  may  be  passed  in  either  direc- 
tion. 

ligature  of  the  Anterior  Tibial  Artery. — A  line  drawn  from 
the  inner  side  of  the  head  of  the  fibula  to  the  center  of  the  ankle- 
joint  will  indicate  the  course  of  the  vessel.  It  lies  upon  the  interos- 
seus  membrane  in  the  upper  two-thirds,  and  upon  the  anterior  surface 
of  the  tibia  in  the  lower  third.     The  vessel  has  upon  its  inner  side  the 


M  fibula  ani 


tensor  digit  communis. 


A.  tibialis  ant. 
N.  peroneus. 


FIG.   8i. — Topography  of  the  anterior  tibial  artery  in  the  upper  half  of  the  leg  (right  leg, 
viewed  from  the  outside)  (after  Loebker). 


tibialis  anticus,  on  its  outer  side  the  extensor  longus  digitorum  and 
extensor  proprius  hallucis  muscles;  and  in  the  lower  third  it  is  crossed 
by  the  tendon  of  the  latter.  The  anterior  tibial  nerve  lies  to  the  outer 
side,  except  in  the  lower  third,  where  it  may  be  in  front  of  the  artery. 
In  the  upper  third  an  incision  should  be  made  in  the  line  of  the  vessel, 
the  deep  fascia  divided,  and  the  intermuscular  space  found.  On  sepa- 
rating the  muscles  the  vessel  will  be  seen  closely  attached  to  the 
interosseous  membrane.  In  the  lower  third  the  tendon  of  the  extensor 
proprius  hallucis  is  the  best  guide. 

ligature  of  the  Dorsalis  Pedis  Artery. — The  course  of  the 
dorsalis  pedis,  the  continuation  of  the  anterior  tibial  artery,  is  indi- 
cated by  a  line  drawn  from  a  point  midway  between  the  two  malleoli 
to  the  interspace  between  the  first  and  second  metatarsal  bones.  It 
lies  between  the  tendons  of  the  extensor  longus  hallucis  and  the  inner 


THE   LIGATURE    OE  ARTERIES. 


333 


tendon  of  the  extensor  communis  digitorum  ;  and  in  its  lower  part  is  a 
V-shaped  space  between  the  extensor  longus  hallucis  and  the  inner 
fasciculus  of  the  extensor  brevis  digitorum.  It  is  covered  only  by 
the  skin  and  superficial  fascia,  and  rests  upon  the  bones  of  the  tarsus, 
having  the  internal  branch  of  the  anterior  tibial  nerve  generally  on  its 


JV.  peron.  superficialis. 

M.  tibialis  ant. 

A.  tibialis  ant 

N.  peroneus  prof. 

.17.  extensor  halluc.  long. 

M.  extensor  digit,  commun. 


N.  peroneus  superfic. 
N.  peroneus  prof. 

A.  dorsalis  pedis. 
Tendo  tibial,  ant. 
Tendo  extens.  hallucis. 


Ten  din.  extens. 
digit,    commun. 


Fig.  82. — Topography  of  the  anterior  tibial  artery  in  the  lower  half  of  the  leg,  and  of  the 
dorsalis  pedis  (after  Loebker). 

outer  side.     The  incision  should  be  made  over  the  prominence  of  the 
instep  in  the  line  of  the  artery. 

ligature  of  the  Posterior  Tibial  Artery. — The  posterior  tibial 
artery  extends  from  the  lower  border  of  the  popliteus  muscle,  at  a 
point  midway  between  the  head  of  the  fibula  and  the  internal  tuberosity 


334 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


of  the  tibia,  to  the  center  of  a  line  drawn  from  the  tip  of  the  internal 
malleolus  to  the  prominence  of  the  heel,  thus  inclining  gradually  to 
the  inner  side  of  the  leg.  In  its  upper  part  it  is  very  deeply  placed, 
being  covered  by  the  gastrocnemius  and  soleus  and  firmly  bound 
down  to  the  fascia  covering  the  deep  group  of  muscles,  the  tibialis 
posticus  and  the  long  flcxcr  of  the   toes ;  but  as  it  approaches  the 


Fascia  of  the  deep 
muscle  layer. 


A.  tibialis  post.- 


N.  tibialis. 


M.  gastrocnem. 


M.  soleus. 


Fig.  83. — Topography  of  the  posterior  tibial  artery  in  the   middle  of  the  leg  (right  leg,  seen 
from   the   inside)  (after  Loebker). 


ankle-joint  it  becomes  much  more  superficial,  and  in  the  lower  third  is 
covered  only  by  skin  and  fascia. 

Ligature  High. — In  the  upper  two-thirds  of  the  leg  the  vessel  is 
so  difficult  to  reach  that  the  operation  is  rarely  done.  The  leg  should 
be  flexed  at  a  right  angle,  so  placed  that  the  internal  aspect  is  readily 
accessible,  and  a  free  incision  made  a  finger's  breadth  posterior  to  the 
inner  border  of  the  tibia.  The  internal  head  of  the  gastrocnemius  is 
pushed  aside,  and  the  attachment  of  the  soleus  to  the  tibia  divided 
h  inch  from  the  bone.  The  deep  intermuscular  fascia  will  then  come 
into  view,  and  the  muscular  planes   may  be  readily  separated.     The 


AMPUTA  TIONS. 


335 


artery  will  be  found  lying  upon  the  tibialis  posticus  muscle,  with  the 
nerve  to  the  outer  side. 

Ligature  Low. — The  artery  is  readily  reached  at  the  point  where 
it  passes  behind  the  internal  malleolus,  having  the  tendons  of  the 
tibialis  posticus  and  flexor  longus  digitorum  between  it  and  the  mal- 
leolus, and  the  tendon  of  the  flexor  longus  hallucis  behind.  At  this 
point  the  nerve  generally  lies  posterior  to  the  arteiy ;  but  it  may  have 
divided  above  this  point,  when  the  artery  will  be  found  between  the 


A.  tibialis  post 
N.  plantaris 


Fig.  84. — Topography  of  the  posterior   tibial   artery  in  the  region  of  the  ankle-joint  (aftei 

Loebker). 

two  branches.    A  curved  incision,  a  finger's  breadth  behind  the  internal 
malleolus,  will  readily  expose  the  vessel. 

AMPUTATIONS. 

General  Considerations. — This  class  of  operations  may  become 
necessary  because  of  injury,  disease,  or  malformation.  For  the  first 
cause,  in  the  conservative  surgery  of  to-day,  amputations  are  far  less 
common  than  formerly.  In  the  second  class  are  included  all  infec- 
tious and  septic  cases.  Operations  performed  immediately  after  the 
injury  are  said  to  be  primary.  If  necessary  later,  from  extension 
of  the  septic  process,  or  to  save  life,  they  are  called  intermediate.  If 
for  improving  the  usefulness  of  the  part,  or  for  other  reasons,  after 
healing  has  taken  place,  they  are  called  secondary. 

Amputations  are  said  to  be  in  continuity  when  the  bone  is  sawed 
through  ;  in  contiguity,  when  at  the  level  of  the  joint  the  limb  is  dis- 
articulated. 

In  these  three  classes  of  causes  the  success  of  the  operation  may  be 


33^  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

said  to  depend  upon  factors  that  are  common  to  all ;  for  instance,  to 
the  shock  of  an  operation  must  be  added,  in  cases  of  injury,  the  shod: 
of  the  original  cause.  Therefore,  for  an  injury  it  is  the  rule  to  ampu- 
tate as  low  as  possible,  to  ODtain  a  viable  stump,  even  at  the  risk  of 
leaving  a  less  perfect  stump,  as  the  shock  of  the  amputation  varies  directly 
with  the  length  of  the  part  amputated. 

Shock  in  these  cases  also  varies  directly  with  the  amount  of  hem- 
orrhage and  the  duration  of  the  operation  ;  hence  celerity,  combined 
with  due  attention  to  hemorrhage,  is  an  important  factor.  On  the 
other  hand,  in  malignant  disease  it  is  all-important  to  remove  the 
disease  entirely,  with  sufficient  margin ;  and  in  malformation  most 
attention  must  be  paid  to  the  resultant  stump. 

The  resultant  stump  is  to  be  considered  from  its  locality  as  suc- 
cessful, in  the  hand  or  foot,  for  its  non-interference  with  other  mem- 
bers, and  somewhat  for  its  appearance  ;  in  the  arm,  for  the  facile 
attachment  of  an  artificial  hand  ;  and  in  the  leg  and  thigh,  primarily 
for  their  weight-bearing  function,  absolute  insensitiveness  is  essential. 
The  dangers  to  be  avoided  in  the  stump  are,  in  the  skin,  overten- 
sion,  which  may  interfere  with  nutrition  ;  in  the  muscle-flap,  insuffi- 
cient blood-supply,  which  may  delay  healing  ;  and  in  the  bone,  rough 
edges  or  careless  laceration  of  the  periosteum,  which  will  give  trouble 
in  the  stump  by  undue  proliferation  or  necrosis.  Nerves  may  also  be 
caught  in  the  scar,  and  be  a  cause  of  much  pain. 

In  general,  to  obtain  a  good  result,  the  skin-flap  should  be  cut  long 
enough  to  cover  the  stump  without  drawing  tightly,  without  being  so 
loose  as  to  cause  redundancy  ;  the  latter  being  the  lesser  evil,  but 
retarding  somewhat  the  hardening  of  the  stump  into  condition  to  sup- 
port apparatus.  The  scar  will  then  be  freely  movable  over  the  under- 
lying parts,  and  should  be  out  of  the  way  of  pressure  ;  for  instance,  in 
the  fingers  the  scar  should  be  on  the  back ;  in  the  leg,  it  should  be  to 
one  side. 

The  muscle-flap  should  closely  approximate  to  its  fellow  or  should 
itself  cover  the  bone.  Nerves  should  be  cut  short  and  allowed  to 
retract:  they  will  then  be  out  of  the  way  of  pressure  in  the  scar,  and 
then,  even  if  "bulbs"  form,  they  will  probably  give  no  trouble.  Ten- 
dons and  fibrous  tissue  should  also  be  cut  short,  for  their  blood-supply 
is  never  too  good;  and  they  are  likely  to  turn  under  the  long  ampu- 
tating-knife  and  leave  ragged  edges. 

The  pathological  changes  which  take  place  in  the  stump  are  repre- 
sented by  atrophy  of  the  muscles  and  a  general  increase  of  connective 
tissue.  Occasionally,  in  a  child,  the  bone  may  continue  to  grow,  and 
this  cannot  be  entirely  avoided  ;  but  a  bad  result  may  in  a  measure  be 
prevented  by  sawing  the  bone  especially  short  in  these  patients.  When 
it  occurs,  a  second  operation  is  the  only  remedy.  To  ensure  smooth 
ends  to  the  bones  the  periosteum  should  be  peeled  back  a  short  dis- 
tance before  sawing,  and  then  turned  over  the  end  of  the  bone.  The 
objection  to  this  method — viz.,  that  osteophytes  may  form  and  pro- 
liferation of  the  bone  ensue — need  not  be  seriously  regarded. 

Arteries,  on  the  other  hand,  should  be  left  long,  for  the  double 
purpose  of  nutrition  of  the  stump  and  the  prevention  of  hemorrhage, 


A  MPUTA  TIONS.  337 

their  elasticity  often  drawing  them  back  into  the  tissues,  where  the 
smaller  ones  may  escape  notice  and  give  trouble  later. 

The  necessity  of  drainage  in  the  wound  depends  upon  various  con- 
ditions. Following  injury,  if  the  tissues  are  bruised  or  lacerated  as  far 
up  as  the  field  of  operation,  or  when  absolute  asepsis  is  not  certain, 
the  wound  must  be  drained.  For  this  purpose,  especially  in  the  cases 
in  which  there  is  much  bruising,  a  drainage-tube,  preferably  of  rubber, 
is  placed  in  the  most  dependent  part  of  the  skin-wound,  or  two  are 
placed  in  opposite  corners  of  the  wound,  if  these  are  equally  depend- 
ent. In  cases  less  likely  to  be  followed  by  much  serous  effusion,  a 
small  wick  or  strand  of  gauze,  or,  better  still,  a  small  roll  of  rubber  tissue, 
may  be  placed  in  the  wound,  and  one  or  two  provisional  sutures  placed 
where  the  skin  is  left  open.  These  may  be  tied  twenty-four  hours 
later,  when  the  wick  is  removed.  In  other  cases,  when  the  condi- 
tion of  the  patient  is  such  that  haste  is  all-important,  the  whole 
wound  may  be  packed  with  gauze,  with  or  without  provisional  stitches 
in  the  flaps.  The  gauze  is  removed  as  indicated  when  the  wound  is 
dry  and  the  patient  has  recovered  from  the  shock  of  the  operation. 
This,  of  course,  is  not  intended  to  apply  to  amputations  following  acute 
infectious  processes,  where  the  wound  is  necessarily  left  open  and  kept 
moist  with  antiseptics,  in  direct  opposition  to  the  drying  and  close 
suturing  of  flaps  which  favor  rapid  healing  in  aseptic  cases. 

Much  of  the  close  apposition  desired  is  gained  by  a  proper  dressing. 
The  stump  should  be  placed  on  a  straight  splint  which  extends  beyond 
the  end  of  the  stump,  and  must  not  be  too  broad,  since  that  will  cause 
the  stump  to  flatten,  and  the  pressure  cannot  be  evenly  distributed. 
The  dressing  should  be  not  too  voluminous,  larger  in  cases  with  drain- 
age than  in  those  without  it,  and  should  be  both  absorbent  and  elastic. 
These  qualities  are  combined  in  a  dressing  of  absorbent  gauze,  with  a 
layer  of  absorbent  cotton,  and  over  all  sheet  wadding  ;  the  whole,  of 
course,  sterilized.  Bandages  are  applied  with  even  pressure,  tight 
enough  to  obliterate  any  dead  space,  but  not  so  tight  as  to  impede  the 
circulation. 

Methods  of  Controlling  Hemorrhage — Hemorrhage  is  a  very 
important  feature.  Secondary  hemorrhage  has  been  a  most  frequent 
cause  of  fatal  results  ;  and  free  bleeding  of  small,  retracted  vessels 
results  in  clot-formation,  which  clot  may  break  down  and  suppurate, 
causing  healing  by  second  intention  even  under  careful  aseptic  precau- 
tions. Hemorrhage  is  controlled  at  the  time  of  operation  by  various 
methods.  The  main  artery  supplying  the  part  is  held  either  by  the 
hand  of  an  assistant  or  by  a  tourniquet.  This  may  be  one  of  several 
patterns.  It  was  originally  a  pad  placed  over  the  artery  under  a  few 
turns  of  a  bandage,  which  bandage  was  tightened  by  drawing  over  a 
short  stick  that  was  turned  till  pulsation  ceased  in  the  part  below. 
Such  a  tourniquet,  modified  and  improved,  is  represented  in  the  Petit 
tourniquet  (Fig.  85).  It  may  consist  of  a  steel  band,  with  two  pads 
where  the  blood-supply  is  double,  as  at  the  wrist,  tightened  by  a  screw 
at  the  side.  The  ordinary  rubber  tubing  tourniquet,  applied  with  one 
or  more  turns,  is  the  best  method  of  control,  and  it  has  superseded  all 
other  devices.  The  tissues  may  be  rendered  more  or  less  bloodless  by 
22 


338 


INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 


elevation  of  the  limb  or  by  the  application  of  the  rubber  bandage  (Es- 
march).  This  has  sonic  disadvantages  in  that  it  may  drive  a  thrombus, 
septic  material,  or  minute  particles  of  malignant  disease  into  the  gen- 
eral circulation.  The  advantage  of  throwing  the  blood  of  the  part  into 
the  rest  bf  the  vascular  system  is  questionable  except  in  cases  of  very 
low  blood-pressure;  and  there  is  danger  of  too  much  vasomotor  paral- 
ysis occurring  as  a  result  of  the  pressure  of  the  bandage,  so  that  when 

the  tourniquet  is  removed  the 
field  of  operation  itself  has  an 
engorged  and  sluggish  circu- 
lation. 

In  the  wound  itself  each  ves- 
sel, as  seen,  should  be  secured 
with  a  ligature  of  the  selected 
material,  tied  firmly  but  not  too 
tightly.  Ballance  and  Edmunds 
have  shown  conclusively  that  to 
occlude  an  artery  it  is  not  neces- 
sary to  rupture  any  of  the  coats, 
and  that  the  danger  of  secondary 
hemorrhage  is  even  less  where 
the  coats  are  left  intact.  A  broad 
ligature,  ensuring  apposition  of 
the  intima  for  a  certain  distance, 
is  best — either  an  animal  tendon, 
chromic  catgut,  or  silk.  Having 
secured  all  the  larger  vessels,  the 
wound  is  sponged  dry  and  the 
tourniquet  loosened  gradually. 
As  the  smaller  vessels  reveal 
themselves,  they  in  turn  are 
picked  up  and  tied.  General 
oozing  is  treated  by  a  thorough 
flushing  with  a  hot  saline  solu- 
tion or  with  very  dilute  anti- 
septics, after  which  the  wound  is 
sponged  dry  and  closed.  Care 
must  be  taken  that  the  ligature  is  far  enough  from  the  end  of  the  ves- 
sel not  to  slip  off,  and  that  the  first  hitch  does  not  slip — that  is,  become 
loosened.  The  second  hitch,  taken  in  the  opposite  direction,  completes 
the  "  reef  or  square  knot,"  as  illustrated  in  Fig.  86.  Some  surgeons 
prefer  to  make  the  first  a  "  surgeon's  knot,"  which  is  simply  an  extra 
turn  on  the  thread.  This  does  not  slip,  but  has  the  disadvantage  of 
not  pulling  up  smoothly,  and  it  is  difficult  to  estimate  the  amount  of 
force  required.  If  a  second  hitch  is  made  over  it,  the  knot  is  too  thick  ; 
without  the  second  hitch  it  is  not  reliable.  Serious  and  even  fatal 
hemorrhages  have  followed  its  use.  The  last  step  is  the  closing  of 
the  wound  and  the  application  of  the  pressure-dressing. 

The  preparation  for  an  amputation  consists  in  the  aseptic  and  anti- 
septic precautions  described  in  the  preceding  chapter,  the  preparing  of 


FlG.  85. — Petit's  tourniquet. 


Fig.  86. — Square  knot. 


AMPUTA  TIONS. 


339 


a  splint  and  dressing,  and  the  instruments  as  given  below.  An  ampu- 
tating-knife  and,  if  desired,  a  smaller  blade  for  dissection  of  the  skin- 
flap  are  needed.'  If  there  are  two  bones  in  the  amputation,  as  in  the 
forearm  and  leg,  then  the  catlin  knife,  with  both  edges  sharpened,  is 


FIG.  87. — Amputation-knives  for  ordinary  use. 


necessary ;  also  scissors,  toothed  dissecting-forceps  and  artery- forceps, 
compression  or  hemostatic  forceps,  bone-cutting  forceps  for  trimming 
rough  edges,  if  necessary,  or  for  cutting  the  bone  itself;  but  too  large 
bones  or  edges  must  not  be  cut  with  these,  as  splintering  occurs.     Lion- 


UM!J_ 


Fig.  88. — Catlin  amputating-knife. 

jawed  forceps  are  of  use  in  holding  or  manipulating  the  bone,  espe- 
cially in  amputations  in  contiguity.  Retractors  of  various  patterns  may 
be  used,  or  spatuiae  ;  but  generally  two  gauze  strips  crossed,  with  a 
third  between  the  bones  if  there  are  to  be  two,  afford  most  efficient 
retraction.  There  should  be  a  periosteum-elevator ;  and  last,  the  saw, 
which  should  be  strong,  with  closely  set  teeth.  In  addition  to  these, 
there  must  be  needles  with  sutures,  and  ligatures  of  the  selected 
material ;  and  drainage-materials,  if  these  are  to  be  used. 

Methods  of  Amputating'. — Operations  may  be  divided  into  two 
general  classes — the  skin-flap  and  the  vntsclc-flap.  These  are  subdi- 
vided into  circular  and  oval  methods.  These  classes  are  not  generally 
recognized,  but  seem  to  be  clearly  distinguished,  as  the  circular  method, 
described  by  all  authors,  is  done  under  the  one  class  or  the  other  inde- 
pendently. For  instance,  in  the  thigh  the  knife  sweeps  first  through 
the  skin  (which  is  retracted) ;  second,  through  the  superficial  muscles, 
these  in  turn  being  retracted ;  three  or  four  sweeps  reach  the  bone, 
which  is  then  sawed  through,  and  is  found  to  be  the  apex  of  a  cone- 
shaped  wound,  the  sides  of  which,  when  closed,  approximate  the  cut 
surfaces  of  the  muscle  to  each  other,  while  the  fascia  and  skin  come 
together  over  all.  Properly  speaking,  this  is  a  muscle-flap  operation. 
But,  on  the  other  hand,  in  the  forearm  the  circular  cut  is  made  through 
the  skin  alone,  which  is  then  dissected  back,  and  the  muscles  are  cut 
directly  through  to  the  bones,  which  are  sawed  high  in  the  wound. 
The  skin  is  closed  directly  over  the  cut  muscle-edges.  This  is  a  skin- 
flap  operation. 

The  Circular  Method. — The  surgeon  should  stand  beside  the 
patient,  so  that  his  left  hand  may  grasp  the  limb  to  be  operated 
upon  on  the  proximal  side  of  the  line  of  amputation.     While  the  part 


340  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

to  be  amputated  is  held  by  an  assistant,  another  draws  the  skin-tissues 
firmly  upward.  The  incision  is  begun  at  the  top,  the  surgeon's  arm 
being  passed  under  and  to  the  further  side  of  the  limb,  and  the  knife 
held  point  upward,  with  the  blade  toward  him.  A  single  slow  sweep 
of  the  knife  carries  the  incision  through  the  skin  and  subcutaneous 
tissues  to  the  muscle-fascia,  completely  around  the  part,  ending  at  the 
starting-point.  The  skin  is  then  dissected  back  a  short  distance,  and  a 
second  sweep  of  the  knife  in  the  same  manner  cuts  the  superficial 
muscles  ;  while  these  are  held  retracted  a  third  cut  completes  the  inci- 
sion to  the  bone.  With  a  periosteum-elevator  the  periosteum  is 
stripped  back  from  the  cut  which  the  last  sweep  of  the  knife  has  made, 
and  the  saw  is  applied  }  to  \  inch  higher.  The  sawing  should  be  done 
slowly  at  first,  to  avoid  jumping  of  the  saw,  and  very  slowly  just  before 
the  bone  is  cut  through,  to  avoid  splintering.  The  left  arm  of  the  sur- 
geon will  naturally  be  held  in  a  line  parallel  with  the  working  of  the 
saw,  and  the  assistant  who  is  holding  the  part  should  also  have  his  arm 
parallel,  not  at  right  angles,  as  he  can  then  firmly  resist  the  thrust  of 
the  saw.  To  prevent  the  bone  binding  the  saw  in  the  cut,  the  bone 
should  also  be  held  somewhat  against  the  saw,  but  without  force,  or 
the  bone  will  be  broken  and  splintered  before  the  saw  cuts  through. 
If  there  are  two  bones  to  be  sawed  through,  the  saw  should  be  applied 
to  the  larger  first ;  and  when  a  groove  is  made,  the  smaller  bone  is  cut 
through,  the  saw  running  in  this  groove  as  a  guide.  Finally,  the 
larger  bone  is  cut  through.  Any  sharp  edges  are  trimmed  with  the 
cutting-forceps,  the  periosteum  drawn  forward  over  the  end  of  the  bone, 
and  the  wound  closed. 

The  Method  by  Circular  Skin=flap. — The  above  description  applies 
to  this  method,  save  that  the  skin  is  dissected  a  little  further  back,  and 
the  muscle-incision  is  carried  at  once  to  the  bone. 

The  Oval  Method. — Where,  for  any  reason,  it  is  desired  that  the 
scar  shall  not  be  terminal,  it  may  be  made  lateral  by  one  of  the  oval 
methods,  which  may  be  either  of  muscle  or  of  skin-flap.  The  muscle- 
flap  operation  may  be  done  by  transfixion  or  from  the  outside.  Trans- 
fixion is  the  method  of  surgeons  of  earlier  days,  and  belongs  to  times 
when  brilliancy  and  speed  were  accounted  of  most  value.  There  is 
much,  however,  to  be  said  for  it,  as  with  a  thin  but  sufficiently  rigid 
knife,  I  or  2  inches  longer  than  the  diameter  of  the  limb,  a  beautifully 
clean  cut  can  be  made.  The  knife  is  thrust  directly  through  the  limb, 
at  the  level  where  the  bone  is  to  be  sawed,  and  passes  just  over  the 
bone  at  this  point,  and  out  at  the  other  side,  the  cutting-edge  facing 
toward  the  extremity.  It  is  then  brought  directly  out  through  all 
opposing  tissues  to  the  point  on  the  surface  where  the  lowest  part  of 
the  long  flap  is  designed  to  be.  This  flap  is  turned  back,  the  bone 
sawed,  and  the  muscles  and  skin  cut  straight  through  to  the  opposite 
side.  The  line  of  scar  will  then  be  on  the  side  opposite  the  long  flap. 
Variations  of  this  method  have  received  special  names,  as  the  long 
anterior  flap  operation,  and  the  rectangular  flap  or  the  lateral  flap. 

To  accomplish  this  result  as  to  the  location  of  the  scar  in  the  class 
of  skin-flap  operations,  similar  incisions  are  made  through  the  skin 
alone.     In  the   oval  incision   the  knife  starts  on  one  side  and  passes 


A  MP  UTA  TIONS.  3  4 1 

obliquely  downward  and  across,  is  transverse  on  the  opposite  side,  and 
comes  obliquely  upward  and  across  to  the  starting-point.  The  most 
frequent  variation  of  this  is  the  so-called  racket  method,  which  has  a 
straight  vertical  incision  at  the  start,  is  oblique  on  the  sides,  and  oppo- 
site to  the  beginning  of  the  incision.  It  is  much  used  in  amputations 
at  the  metacarpophalangeal  joints,  having  the  advantages  of  neatness 
and  bringing  the  scar  entirely  out  of  the  grasping  surface  of  the  hand. 

Another  modification  of  this  is  to  cut  two  oval  flaps,  equal  or 
unequal  in  length,  the  advantage  of  which  is  the  avoidance  of  the 
corners  which  are  present  in  the  circular  flap  operation,  and  the  bring- 
ing together  of  the  skin  smoothly,  with  even  pressure,  over  the 
rounded  stump. 

Amputation  of  the  Fingers. — Because,  in  the  majority  of  cases, 
amputation  of  a  finger  is  necessitated  by  trauma,  the  surgeon  often 
has  to  adapt  his  methods  to  the  case.  When  possible,  however,  a 
long  flap  should  be  taken  from  the  palmar  surface,  in  order  that  the 
most  sensitive  skin  shall  be  on  the  palmar  and  the  cicatrix  on  the  dorsal 
surface.  It  is  of  prime  importance  to  save  every  possible  part  of  the 
hand  or  finger  (except  in  malignant  disease),  as  no  apparatus  can  ever 
compensate,  and  the  most  unpromising  stumps  are  of  use.  In  ampu- 
tating through  a  joint,  the  finger  should  be  flexed,  the  joint  opened,  a 
long  palmar  flap  made  by  keeping  the  knife  close  to  the  under  surface 
of  the  distal  bone,  and  the  flap  turned  over  to  meet  a  short  dorsal 
one,  thus  bringing  the  scar  on  the  back.  The  same  flaps  should  be 
made  when  amputating  through  a  phalanx.  The  vessels  are  on  either 
side  of  the  finger,  and  bleeding  may  be  controlled  by  pressure  or 
sutures. 

Amputation  through  the  Metacarpophalangeal  Articulations. — In 
the  removal  of  an  entire  finger,  an  incision  should  be  made  about 
\  inch  above  the  joint  on  the  dorsal  surface,  and  carried  around  the 
finger  to  a  point  f  inch  from  the  wreb  on  the  palmar  surface ;  and  a 
similar  incision  should  be  made  on  the  other  side  of  the  finger  to  meet 
it.  The  soft  structures  are  then  divided,  the  finger  removed,  and  the 
flaps  trimmed  and  brought  together. 

The  incisions  should  be  modified  for  each  finger,  in  order  to  bring 
the  resulting  scar  as  far  from  the  palmar  surface  as  possible.  A 
long  palmar  flap  may  be  used,  or  the  incision  known  as  Malgaigne's 
racket  may  be  made,  which  is  somewhat  of  a  Y-shape,  the  handle 
being  on  the  dorsal  surface.  Several  fingers  may  be  removed  at  once, 
although  it  is  advisable  to  remove  each  separately  by  the  most  suit- 
able incision.  Hemorrhage  can  be  controlled  by  ligatures  or  pressure 
(Fig.  89). 

Amputation  of  the  Metacarpal  Bones. — The  removal  of  a 
metacarpal  bone  along  with  the  finger  is  an  operation  not  often  done. 
The  usual  way  is  to  remove  the  finger  with  part  of  the  metacarpal, 
which  is  a  much  simpler  procedure.  However,  it  is  sometimes  neces- 
sary to  remove  the  first  or  fifth  metacarpal  entire.  This  is  attended 
with  less  difficulty,  as  the  tendon-sheaths  over  these  bones  do  not  com- 
municate directly  with  the  other  synovial  sheaths  in. the  palm,  and  thus 
danger  of  infection  of  the  wrist-joint  is  avoided.  The  same  incision  is 
used  as  for  amputation   at  the  metacarpophalangeal  joint,  the  dorsal 


342 


INTERNA  TIONAL    TEXT-BOOK  OF  SI  RGE  R  \ 


incision  being  carried  far  enough  up  to  expose  the  bone  (Malgaigne's 
racket)  (Fig.  90).  The  soft  parts  are  carefully  separated,  and  the  bone 
cut  with  forceps  or  disarticulated,  as  the  case  may  be.  Great  care 
must  be  taken  not  to  injure  the  palmar  arch,  which  crosses  on  the 
palmar  side  of  the  bones  near  to  the  proximal  ends.  In  removing  the 
first  metacarpal,  the  operator  should  remember  the  relation  of  the 
radial  artery,  which  passes  around  its  ulnar  side.  The  fifth  metacarpal 
is  more  accessible  from  a  lateral  incision. 

Amputation    at   the  Wrist.— Circular   Method   (Fig.  91).— In 


FlG.  89. — Dorsal  view  of  hand.  Exartic- 
ulation  of  the  fingers  by  racket  incisions: 
b,  exarticulation  of  the  thumb  by  flap  in- 
cision; a  a,  exarticulation  of  the  hand  by 
long  dorsal  flap. 


FlG.  90. — Hand,  view    from  dorsal  side  : 

a,  exarticulation  of  the  index  finger  at  the 
carpometacarpal  joint  with  racket  incision  ; 

b,  exarticulation  of  the  third  and  fourth 
metacarpal  bones  with  oval  incision  ;  c,  ex- 
articulation of  the  fifth  metacarpal  bone  with 
flap  incision. 


this  method  the  surgeon  makes  a  circular  incision  about  the  wrist, 
beginning  on  the  radial  side.  The  incision  should  begin  about  \  inch 
below  the  styloid  process  of  the  ulna,  and  incline  somewhat  lower 
toward  the  radial  side,  as  the  styloid  process  of  the  radius  is  the  longer. 

The  skin  is  then  dissected  off  and  reflected  back  as  a  cuff,  both 
styloids  being  exposed.  The  hand  is  sharply  flexed,  and  the  soft 
parts  divided,  beginning  at  the  radial  side,  with  the  external  lateral 
ligament  and  extensor  tendons,  then  the  internal  lateral  ligament  and 
anterior  ligament,  finally  coming  through  the  joint  and  cutting  the 
flexor  tendons  last.  The  vessels  are  the  radial,  the  ulna,  and  the  ante- 
rior interosseous. 

Anteroposterior  Flaps. — Here  two  equal  flaps  are  made,  one  from 
each   surface.     For  the  dorsal  flap  a  curved  incision  from  one  styloid 


AAIPUTA  TIONS.  343 

to  the  other  is  made,  a  similar  one  being  cut  from  the  palmar  surface. 
The  flaps  are  turned  back  and  the  soft  parts  divided.  Amputation 
with  the  long  palmar  flap  needs  little  explanation.  It  is  a  modification 
of  the  other  method.  The  palmar  flap  extends  from  just  below  the 
styloids  to  the  middle  of  the  metacarpal  bones  in  a  U  shape  (Fig.  91,  b),' 
the  dorsal  incision  being  a  straight  cut  over  the  articulation,  joining 
the  two  ends  of  the  U. 

External  Lateral  Flap. — This  is  known  as  Dubrueil's1  operation, 
and  may  be  briefly  described  as  follows :  The  incision  is  begun  at  the 
back  of  the  wrist,  at  the  junction  of  the  outer  and  middle  thirds,  and 
\  inch  below  the  line  of  the  wrist-joint,  is  carried  downward  toward  the 
thumb,  and,  crossing  the  first  metacarpal  bone  at  its  middle,  returns  to 
a  point  on  the  palmar  surface  opposite  its   starting-place.     Dissecting 


FIG.  91. — Palmar  view  of  hand,  showing  circular  method  of  amputation  at  the  wrist  (a  b) ;  long 
palmar  flap  (b) ;   Dubrueil's  incision  (a  c). 

the  flap  to  its  base,  making  it  as  thick  as  possible,  the  skin  and  soft 
parts  internal  to  the  flap  are  now  divided  by  a  circular  cut  on  a  level 
with  the  base  of  the  flap.  Disarticulation  is  thus  effected,  and  the 
flap  is  brought  transversely  across  and  sutured  (Fig.  91,  a  c). 

Amputation  of  the  Forearm. — All  authorities  agree  that  the 
circular  method  is  the  best  for  amputation  of  the  lower  third,  and  the 
flap  method  for  the  other  two-thirds.  In  the  circular  method  "the 
skin-cut  is  made  at  a  distance  below  the  future  saw-line  equal  to  the 
anteroposterior  diameter  of  the  limb  at  that  line  "  (Treves).  The  soft 
parts,  principally  tendons,  are  best  divided  by  transfixion  from  within 
outward.  In  sawing  the  bones  it  is  best  to  saw  the  radius  first,  then 
the  ulna,  the  radius  being  the  movable  bone.     In  the  anteroposterior 

1  For  full  description  see  Chalot  [Chirurgie  Operatoire,  1886). 


344  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

flap  method  the  flaps  should  be  marked  in  the  skin  with  a  knife,  and 
after  retraction  has  taken  place  two  equal  muscle-flaps  from  the  ante- 
rior and  posterior  surfaces  should  be  cut  by  transfixion  (Fig.  92). 

Another  method,  which  is  suitable  for  use  in  any  part  of  the  arm, 
is  to  make  two  curved  skin-flaps  and  divide  the  other  soft  parts  by  a 
circular  cut.     The  skin-flaps  may  be  of  equal  length,  or  the  posterior 


FlG.  92. — Amputation  of  the  forearm  :   I.  Flap  method,  posterior  view. 

circular  method  {a  a). 


Flap  method  (b  b) : 


one  somewhat  the  longer.  The  vessels  are  the  radial,  ulnar,  anterior 
and  posterior  interossei. 

Amputation  at  the  Elbow-joint. — There  are  several  methods 
described  for  this  operation  :  the  anterior  flap,  the  circular,  the  lateral 
flap,  and  the  elliptical. 

Anterior  Flap  Method. — With  the  arm  extended  and  the  hand  in 
supination,  an  anterior  skin-incision  Is  made  beginning  at  a  point  an 
inch  below  the  joint  on  the  ulnar  side,  extending  in  a  long  curve  to 
about  3!  inches  from  the  bend  of  the  elbow,  and  terminating  if  inches 
below  the  external  condyle.  This  will  give  a  U-shaped  flap.  The 
ends  of  the  anterior  cut  are  joined  by  a  posterior  one.  Some  operators 
prefer  to  do  this  by  making  a  short  posterior  flap.  After  the  skin  has 
been  retracted,  the  anterior  muscle-flap  is  cut  by  transfixion  and  lifted 
up,  and    any  deep  muscle-fibers  that    may  be   left  are  divided.     The 


AMPUTATIONS. 


345 


joint  is  then  opened  by  dividing  the  anterior  ligament,  then  the  late- 
ral ligaments,  and  the  disarticulation  is  completed  by  cutting  the  pos- 
terior* ligament  and  the  triceps  tendon  (Fig.  93,  c).    The  vessels  are  the 


Fig.  93. — a,  Amputation  of  the  upper  arm, 
flap  method  ;  b,  disarticulation  of  the  elbow  ; 
c,  anterior  flap  method. 


Fig.    94. — Disarticulation    of    the    elbow- 
equal  flaps  (e) ;  long  external  flaps  (d). 


brachial,  or  the  radial  and  ulna,  according  as  the  bifurcation  of  the 
brachial  is  high  or  low. 

The  Lateral  Flap  Method. — This  operation  may  be  done  with  one 
long  external  flap,  or  an  external  and  an  internal  flap.  The  external 
flap  should  be  made  by  transfixion,  the  knife  entering  close  to  the  head 
of  the  radius  and  emerging  at  the  back  of  the  joint,  on  a  level  with  it, 
near  the  olecranon.  The  knife  is  carried  downward,  cutting  a  flap  4 
inches  long.  The  ends  of  the  external  incision  are  now  joined  by  an 
internal  incision.  Disarticulation  is  effected  by  opening  the  joint  from 
the  radial  side. 

Amputation  of  the  Arm  1  Fig.  93). — This  operation  may  be  per- 
formed by  any  of  the  recognized  methods  of  amputation,  the  circular 
being  better  adapted  to  the  lower  part  of  the  member.  The  tissues 
on  the  inner  side  of  the  arm  have  the  greater  power  of  retraction,  and 
this  is  to  be  remembered  in  making  a  circular  cut.  The  method  which 
is  recommended  by  Wyeth  and  others  can  be  used  on  any  portion  of 
the  arm.     It  consists  of  a  circular  skin-incision,  made  with  a  slant  to 


346 


INTERNATIONAL    TEXT- BO  OK   OF  SURGERY. 


the  inner  side,  and  a  short  incision  at  right  angles  to  it  on  the  outer 
side.  This  enables  one  to  make  a  good  cuff.  The  muscles  are  divided 
by  a  circular  cut  to  the  bone,  parallel  to  the  circular  skin-cut. 

Amputation  at  the  Shoulder-joint. —  The  greatest  difficulty  in 
amputation  at  the  shoulder-joint  lies  in  controlling  hemorrhage ;  the 
Esmarch  tourniquet,  as  used  by  Wyeth,  or  a  preliminary  ligature  or 
digital  compression  of  the  axillary  artery  and  vein  being  required. 
Those  methods  of  amputation  which  afford  the  best  opportunity  for 
securing  the  vessels  have  met  with  the  most  approval,  and  in  general 
provide  for  the  completion  of  the  greater  part  of  the  operation  as  well 
as  for  ready  digital  compression  or  ligature  of  the  vessels  in  the  flap, 
before  their  actual  division. 

The  Oval  Method  (Lari'cy). — An  incision  is  made  from  just  below 
the  acromion  down  the  outer  aspect  of  the  arm,  through  the  deltoid 
muscle  to  the  bone.  This  incision  is  prolonged  for  about  4  inches,  and, 
from  its  middle,  anterior  and  posterior  skin-incisions  are  made,  which 
meet  on  the  internal  surface  of  the  arm  at  the  level  of  the  lower 
extremity  of  the  first  incision.  The  anterior  flap  is  dissected  up,  divid- 
ing the  pectoralis  major  at  its  insertion  and  exposing  the  axillary  artery. 
The  posterior  flap  is  dissected  close  to  the  humerus,  to  avoid  wound- 
ing the  posterior  circumflex  artery.  Upward  pressure  on  the  elbow 
now  puts  the  joint-capsule  on  the  stretch,  so  that  it  may  be  divided 
against  the  head  of  the  humerus,  and  rotation  inward  and  outward 
allows  division  of  the  muscles  in  front  and  behind.  Continued  upward 
pressure  and  abduction  of  the  humeral  head  permit  division  of  the  cap- 
sule and  the  muscular  attachments  below  the  joint.  While  an  assistant 
now  compresses  the  axillary  artery  in  the  anterior  part  of  the  wound, 

a  single  cut  downward  divides  the  vessels 
and  joins  the  original  oval  skin-incision, 
completing  the  disarticulation. 

The  Double  Flap  Method  (Fig.  95). — 
The  muscular  mass  of  the  deltoid  may  be 
used  as  a  flap,  and,  whether  cut  by  trans- 
fixion (Lisfranc)  or  dissected  from  without 
inward,  will  still  permit  the  compression 
of  the  axillary  artery  in  the  wound  before 
its  final  division.  The  incision  will  reach 
from  the  tip  of  the  coracoid  process  in 
front,  downward  nearly  to  the  insertion 
of  the  deltoid,  and  upward  again  to  the 
base  of  the  acromion  behind.  After  this 
U-shaped  flap  is  dissected  up  from  the 
bone  the  joint  is  exposed  and  opened 
from  above,  the  rotators  divided,  and  the 
head  of  the  humerus  drawn  out  from  the 
glenoid  cavity  to  allow  space  enough  for 
the  fingers  of  the  assistant  to  compress 
the  vessel  on  the  axillary  side.  The  am- 
putation is  now  completed  by  a  down- 
ward cut  from  the  humerus  toward  the  chest-wall,  forming  a  short 
internal  flap. 


FiG.  95. — Amputation  at  the 
shoulder-joint:  a  a,  large  external 
flap;  bb,  by  racket  incision. 


AMPUTATIONS. 


347 


Spence's  Method. — This  differs  from  Larrey's  operation  only  in 
detail.  The  incision  is  started  more  on  the  anterior  aspect  of  the  arm, 
near  the  coracoid  process,  and  extends  through  the  insertion  of  the 
pectoralis  major,  then  curves  backward  to  the  posterior  axillary  fold, 
across  the  axillary  aspect  of  the  arm,  and  upward  to  meet  the  other 
incision  over  the  pectoral  insertion.  Dissection  and  division  of  the 
muscles  inserted  into  the  tuberosities  are  more  readily  performed  by 
means  of  this  incision,  although  the  disarticulation  and  control  of  the 
artery  are  the  same  as  in  Larrey's  operation.  Spence's  method  is, 
furthermore,  applicable  particularly  to  cases  in  which  a  preliminary 
incision  and  examination  of  the  joint-structures  are  desired  before 
amputation  is  decided  upon. 

Wyeth's  Method. — The  safest  and  best  way  to  control  hemorrhage 
at  the  shoulder  is  to  employ  Wyeth's  transfixion-pins  in  the  same 
manner  that  they  are  used  at  the  hip-joint  (see  Hip-joint  Amputation, 
P-  363).  One  pin  is  introduced  anteriorly  into  the  clavicular  portion 
of  the  pectoral,  and  brought  out  just  above  its  axillary  border;  the 
other  one  is  thrust  through  the  deltoid  behind  the  joint,  the  point 
being  brought  out  about  3  inches  below  its  entrance.  The  tourniquet 
is  then  wound  tightly  above  them.  The  amputation  may  now  be  done 
without  fear  of  the  tourniquet  slipping. 

Amputation  of  the  Arm,  Scapula,  and  Part  of  the  Clavicle 
{Bergcr). — The  removal  of  the  whole  upper  extremity  requires  a  pre- 


FlG.  96. — Interscapulothoracic  amputation. 


liminary  ligature  of  the  subclavian  vessels.  This  is  best  done  by  the 
method  of  Berger.  An  incision  is  begun  at  the  outer  edge  of  the 
sternomastoid,  and  continued  along  the  clavicle  to  its  acromial  end. 


34» 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


The  periosteum  is  then  divided,  and  the  middle  third  of  the  clavicle 
excised  by  means  of  a  chain-saw,  leaving  a  space  through  which  the 
subclavian  artery  and  vein  can  be  double-tied  and  cut.  From  the 
middle  of  the  anterior  lip  of  the  clavicular  incision  the  knife  is  passed, 
in  an  outward  sweep,  over  the  deltoid  muscle  to  the  outer  end  of  the 
anterior  axillary  fold,  across  the  inner  aspect  of  the  arm,  and  inward 
and  downward  on  the  trunk  to  the  angle  of  the  scapula.  From  this 
point  an  incision  passes  upward  over  the  spine  of  the  scapula  to  join 
the  first  clavicular  incision  at  its  outer  end.  These  incisions  at  first 
involve  only  the  skin ;  but  the  anterior  one  is  now  deepened,  and  its 
edge  raised  and  dissected  back,  as  a  flap,  to  take  in  the  muscular  origins 
of  the  pectoralis  major  and  minor,  which  are  divided  near  their  inser- 
tion. The  nerve-trunks  of  the  brachial  plexus  are  now  cut  at  the  level 
of  the  division  of  the  artery  and  vein,  and  the  anterior  attachments  of 
the  extremity  are  free.  The  latissimus  dorsi  is  now  divided  by  deepen- 
ing the  posterior  incision,  and  upon  reflecting  this  posterior  flap  toward 
the  spine  the  trapezius  is  exposed  and  divided  close  to  the  scapula  and 
clavicle.  The  muscles  now  holding  the  scapula  to  the  trunk — the 
omohyoid,  levator,  serratus,  and  rhomboids — are  divided  from  above 

downward,  and  the  extremity  is  removed. 
The  flaps  come  together  from  before  back- 
ward and  downward,  and  form  a  linear  scar. 
Amputation  of  the  Toes. — A  knowl- 
edge of  the  important  structures  in  the  ante- 
rior part  of  the  foot  is  of  the  greatest  im- 
portance in  amputation  in  this  region.  The 
heads  of  the  metatarsal  bones,  particularly 
the  first  and  fifth,  and  the  base  of  the  first 
phalanx  of  the  great  toe,  are  to  be  preserved 
if  possible  ;  whereas  the  terminal  phalanges 
of  the  other  toes  may  best  be  removed  in 
their  entirety  by  disarticulation  at  the  meta- 
tarsophalangeal joint.  Amputation  of  the 
great  toe  through  the  first  phalanx  may  be 
performed  by  an  oval  or  racket  incision,  com- 
mencing above  the  web,  or  by  a  single 
plantar  flap.  Disarticulation  at  the  meta- 
t  a  r  sop  h  a  1  a  ngeal 
joint  of  the  lesser 
toes  is  best  per- 
formed by  a  racket- 
incision  which  just 
clears  the  web  of 
the  toes  on  its  plan- 
tar surface.  Much 
care  must  be  taken 
to  avoid  a  scar  on  the  plantar  surface,  and,  in 
the  case  of  the  great  toe,  to  provide  sufficient 
soft  parts  to  cover  in  the  bone  (Fig.  97). 

Disarticulation   of    the   Great   Toe   at   the    Metatarsophalangeal 
Joint. — Where  injury  or  disease  of  the  soft  parts  permits,  this  operation 


FlG.  97. — a  a,  Exarticulation  of 
the  great  toe  with  dorsal  and 
plantar  flaps  ;  b,  exarticulation  of 
the  second  toe  with  racket  in- 
cision ;  c,  exarticulation  of  the 
fourth  toe  with  racket  incision  ;  d, 
exarticulation  of  the  small  toe 
with  formation  of  an  outer  flap. 


Fig.  98. — Exarticulation  of 
the  great  toe  with  formation  of 
an  inner  flap. 


AMPUTA  TIONS.  349 

may  be  performed  by  means  of  a  large  internal  flap.  The  incision 
begins  at  the  level  of  the  joint,  and  passes  down  on  the  inner  side  of 
the  dorsum  of  the  toe  to  the  end  of  the  first  phalanx  ;  from  there  it 
turns  inward  around  the  toe  to  the  plantar  surface,  upward  as  far  as 
the  web,  and  back  to  the  first  incision  at  its  beginning.  This  incision 
is  carried  down  to  the  bone,  and  the  flap  thus  formed  is  dissected  back  ; 
the  joint  is  opened  from  above,  and  its  ligaments  divided  on  each  side 
and  behind.  The  sesamoid  bones  are  to  be  left  in  the  stump,  and  the 
open  tendon-sheaths  closed  by  suture;  the  plantar  digital  vessels  will 
require  ligature.  An  oval  or  racket  incision  is  also  used  for  this 
operation,  but  does  not  provide  so  satisfactory  a  covering  for  the  head 
of  the  bone. 

Amputation  of  Two  Adjoining  Toes. — The  racket-incision  is  sus- 
ceptible of  application  in  the  removal  of  two  or  even  three  adjoining 
toes  ;  but  its  beginning  must  be  carried  further  on  the  dorsum,  accord- 
ing to  the  amount  of  space  needed  for  disarticulation.  In  the  case  of 
two  toes  the  incision  will  begin  in  the  space  between  the  two  metatarsal 
bones.  The  operation  is  otherwise  exactly  similar  to  amputation  of  a 
single  toe. 

Amputation  of  the  Metatarsal  Bones. — The  bases  of  the 
metatarsal  bones,  which  receive  parts  of  the  insertion  of  the  tibial 
muscles  and  the  peroneus  longus,  are  of  great  importance  to  the  integ- 
rity of  the  foot,  and  amputation  is  much  to  be  preferred  to  exarticula- 
tion  of  the  entire  bone.  An  elongated  oval  or  racket  incision  may  be 
used,  commencing  where  the  bone  is  to  be  divided,  and  extending 
down  on  the  dorsum,  around  in  the  digitoplantar  fold,  and  back  to  its 
point  of  origin.  The  knife  must  follow  the  bone  closely,  to  avoid 
injury  to  the  digital  arteries,  and  a  saw  is  to  be  preferred  to  cutting- 
forceps  in  dividing  the  bone.  Amputation  of  the  first  and  fifth  meta- 
tarsals may  also  be  done  by  means  of  a  large  internal  or  external  flap. 

Disarticulation  of  all  the  Metatarsal  Bones  {Lisfranc). — Amputa- 
tion of  the  foot  at  the  tarsometatarsal  joint  was  described  by  Lisfranc, 
who  followed  the  anatomical  line  of  separation  of  the  bones  ;  and  by 
Hey,  who  disarticulated  the  outer  three  or  four  metatarsals,  and  sepa- 
rated the  remaining  structures  with  a  saw.  Either  operation  may  be 
chosen,  according  to  the  amount  of  time  at  the  disposal  of  the  opera- 
tor and  the  exigencies  of  the  individual  case.  The  large  plantar  flap 
is  to  be  marked  out  first  by  an  incision  from  over  the  prominent  base 
of  the  fifth  metatarsal,  in  a  broad  sweep  across  the  sole  at  the  heads 
of  the  metatarsals,  and  back  to  a  point  over  the  base  of  the  first  meta- 
tarsal, about  i  inch  in  front  of  the  prominent  tuberosity  of  the  scaphoid 
(Fig.  99). 

The  dorsal  incision,  joining  the  two  ends  of  the  plantar  flap,  is  cut 
with  a  gentle  curve  about  \  inch  anterior  to  the  articulation.  The 
flaps  each  contain  all  the  soft  parts  above  the  bone.  After  dissection,  the 
joints  are  opened  from  above,  beginning  at  the  outer  side,  and  the  fifth, 
fourth,  third,  and  first  metatarsals  are  readily  freed  from  their  attach- 
ments. The  second  metatarsal  is  mortised  between  the  tarsal  bones, 
and  requires  an  incision  in  the  direction  of  the  ankle  to  secure  its  liber- 
ation. Here  Hcys  modification  may  be  adopted,  and  the  saw  used  to  com- 
plete the  division  of  the  bones,  either  by  sawing  across  the  base  of  the 


350  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

second  metatarsal  and  leaving  it  in  position,  or  by  dividing  the  internal 
cuneiform  and  taking  part  of  it  away.  The  original  method  of  Lisfranc 
provided  for  the  formation  of  the  plantar  flap  by  cutting  from  within 
outward  after  separation  of  the  joint ;  but  a  better  flap  will  be  obtained 
by  preliminary  dissection.  The  stump  left  after  this  amputation  is  a 
fairly  serviceable  one,  although  a  tenotomy  of  the  ten  do  Achillis  may 


Fig.  99. — Lisfranc's  or  Hey"s  amputation  of  the  foot. 

be  necessary  to  prevent  contractures  due  to  the  weakened  resistance  to 
the  pull  of  the  great  muscles  of  the  calf. 

Chopart's  Amputation  {Amputatioii  through  the  Mediotarsal  Joint). 
— An  incision  is  made  on  the  plantar  surface  of  the  foot  from  just 
behind  the  tuberosity  of  the  scaphoid  on  the  inner  side,  down  and 
across  the  sole  at  the  middle  of  the  metatarsal  bones,  and  back  to  a 


Fig.  100. — Chopart's  amputation  of  the  foot,  internal  view. 

point  about  I  inch  posterior  to  the  base  of  the  fifth  metatarsal  on  the 
outer  side.  The  two  ends  of  this  incision  are  then  united  by  a  curved 
incision  across  the  dorsum  of  the  foot,  reaching  at  its  lowest  point  to 
the  level  of  the  bases  of  the  metatarsal  bones  (Figs.  100  and  101). 
These  two  flaps  are  dissected  up,  with  all  the  muscles  and  tendons,  as 
far  as  the  mediotarsal  joint.  The  astragaloscaphoid  and  calcaneo- 
cuboid joints  are  now  opened  on  their  dorsal  aspect,  while  the  foot  is 
held  in  strong  plantar  flexion,  and  the  strong  calcaneoscaphoid  liga- 
ment is  divided  by  cutting  outward  and  forward  from  the  astragalo- 


AMPUTA  TIONS. 


351 


scaphoid  articulation.  The  classical  operation  demands  the  removal 
of  the  scaphoid ;  but  a  serviceable  stump  will  be  found  practicable  in 
many  cases  by  carrying  the  incision  between  the  scaphoid  and  cuneiforms, 
and  thus  saving  part  of  the  tibialis  posticus  attachment.  The  divided 
anterior  tendons  can  be  sutured  to  the  dorsal  fasciae,  and  will  exert 
some  slight  action  in  opposing  the  pull  of  the  soleus  and  gastrocnemius ; 
but  a  contraction  is  more  than  likely  to  occur  with  elevation  of  the 
heel,  and  tenotomy  of  the  Achilles  tendon  is  frequently  required.  The 
dorsalis  pedis  artery  anteriorly,  and  the  two  plantar  arteries  in  the  sole, 
will  require  ligature.     The  end-result  of  this  amputation  is,  as  a  rule, 


FlG.  ioi.— Chopart's  amputation  of  the  foot,  external  view. 

a  satisfactory  one,  and  with  suitable  apparatus  no  disability  is  to  be 
expected  (Figs.  100  and  10 1). 

Syme's  Amputation  {Tibiotarsal). — This  operation  for  removal  of 
the  foot  at  the  ankle-joint  is  partly  superseded  at  present  by  more  con- 


Fig.  102. — Syme's  amputation  of  the  foot,  external  view. 

servative  operations,  such  as  Pirogoff' s  ;  but  where  for  any  reason  the 
operations  described  below  are  impossible,  that  of  Syme  will  be  found 
to  give  a  serviceable  stump.  An  incision  is  begun  at  the  tip  of  the 
external  malleolus  on  its  posterior  aspect,  and  carried  perpendicularly 
around  the  foot  under  the  heel  to  a  point  just  below  the  internal  mal- 
leolus. This  incision  is  carried  down  to  the  bone,  and  its  ends  united 
by  a  transverse  incision  across  the  front  of  the  ankle-joint  (Figs.  102 


JD- 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


and  103).  The  capsule  of  the  joint  is  opened,  and  its  lateral  ligaments 
then  divided  from  within  outward  on  each  side.  The  heel-flap  is  now 
dissected  free  from  the  os  calcis,  the  knife  being  directed  close  to  the 
bone  to  avoid  injury  to  the  smaller  vessels  which  supply  the  flap.  The 
soft  parts  are  now  retracted,  to  allow  the  sawing  off  of  the  lower  ex- 
tremity of  the  tibia  and  the  two  malleoli.  There  is  great  danger  of 
injury' to  the  calcaneal  branches  in  dissecting  the  os  calcis;  and  the 
difficulties  of  this  part  of  the  operation  will  be  much  increased  by  a 
too  generous  allowance  in  carrying  the  preliminary  incision  forward  of 
the  perpendicular  in  the  first  place.  The  large  pocket  left  in  the  heel- 
flap  by  removal  of  the  os  calcis  is  best  drained  by  a  special  incision  at 
its  lowest  part,  and  the  insertion  of  a  gauze  wick  or  rubber  drainage- 
tube.  The  anterior  tibial  and  external  and  internal  plantar  are  the 
important  arteries.  The  chief  objections  to  this  operation  are  the 
difficulty  in  dissecting  the  closely  adherent  skin  from  the  os  calcis,  the 
poor  nourishment  of  the  flap,  and  the  unfavorable  conditions  for  pri- 


FlG.  103. — Syme's  amputation  of  the  foot,  internal  view. 

mary  union  afforded  by  the  dead  space  in  the  hollow  heel-cap  (Figs. 
102,  103). 

Amputation  by  Single  Internal  Flap  (Rotix). — This  incision  for  disarticulation 
of  the  foot  at  the  ankle-joint  is  applicable  in  cases  of  injury  to  the  tissues  of  the  heel  so 
severe  as  to  prevent  their  utilization  for  a  Syme  or  a  Pirogoff  amputation.  The  incision 
begins  at  the  tip  of  the  external  malleolus,  crosses  the  dorsum  with  a  gentle  curve  to  a  point 
over  the  scaphoid  tuberosity,  and  reaches  the  middle  line  of  the  sole  of  the  foot  under  the 
line  of  the  internal  malleolus.  From  this  point  it  passes  over  the  tip  of  the  heel  to  the 
outer  side  of  the  Achilles  tendon  and  back  to  its  starting-point.  The  disarticulation  follows 
as  in  Syme's  operation,  and  the  soft  parts  may  be  cut  from  within  outward,  freeing  the  os 
calcis  and  forming  the  flap.  The  articular  surfaces  of  the  tibia  and  fibula  are  then  sawed 
through  and  removed,  together  with  the  malleoli. 

Pirogoff 's  Amputation. — This  operation  is  much  to  be  preferred  to 
Syme's  when  neither  injury  nor  disease  of  the  os  calcis  is  present,  being 
much  simpler  in  execution,  less  liable  to  the  pocketing  of  secretions, 
and  giving  a  longer  stump  with  a  better  bearing  surface.  Many  modi- 
fications of  the  original  Pirogoff  amputation  have  been  suggested,  and 
some  variation  must  be  allowed  for  individual  cases.  The  incisions  for 
the  Pirogoff  amputation  are  as  follows:  From  the  point  of  the  internal 
malleolus  downward  and  across  the  sole  to  a  point  in  front  of  the  tip 
of  the  external  malleolus,  the  incision  being  at  right  angles  to  the  long 


AMPUTA  TIONS.  353 

axis  of  the  foot.  Another  incision  joins  the  two  ends  of  the  first  one 
across  the  front  of  the  ankle  just  below  the  joint.  After  preliminary 
retraction  of  the  skin,  these  incisions  are  carried  through  the  soft  parts 
of  the  bone.     The  joint  is  now  opened  anteriorly,  the  strong  lateral 


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Fig.  104. — Pirogoff's  amputation  of  the  foot,  external  view. 

ligaments  divided  as  in  Syme's  amputation,  and  the  posterior  ligament 
cut  through.  The  foot  is  now  carried  into  strong  plantar  flexion,  and 
the  saw  placed  upon  the  upper  surface  of  the  os  calcis,  behind  the 
astragalus.  The  saw-cut  follows  the  line  of  the  first  incision,  removing 
all  of  the  foot  but  the  posterior  part  of  the  os  calcis  embedded  in  the 
tissues  of  the  heel.     The  malleoli  and  the  articular  surface  of  the  tibia 


FIG.  105. — Pirogoff's  amputation  of  the  foot,  internal  view. 

are  now  sawed  off,  and  the  two  sawed  surfaces   of  tibia  and  os  calcis 
brought  together  and  held  with  sutures  (Fig.    106). 

Modifications  in  the  line  of  the  saw-cuts  have  been  made  with  the 
view  to  bringing  the  bearing  surface  of  the  stump  more  on  the  thick 
sole  and  less  on  the  thin  surface  at  the  back  of  the  heel.  To  this 
end,  the  first  incision  may  be  carried  as  far  forward  as  the  calcaneo- 
cuboid articulation,  and  the  saw-cut  made  to  come  out  just  posterior  to 
the  articulating  surface.  More  may  also  be  taken  from  the  front  than 
from  the  back  of  the  tibia,  with  the  same  result,  causing  less  rotation  of 

23 


354 


INTERNATIONAL    TEXT- BO  OK  OF  SURGE  RY. 


the  heel-flap  (Sedillot).  The  os  calcis  may  also  be  sawed  in  a  horizontal 
direction,  and  disarticulated  in  front  from  the  cuboid  to  complete  its 
removal  (Le   Fort).     Tenotomy  of  the  Achilles  tendon  is  practically 


FlG.  106. — Lines  of  bone-cuts  in  Pirogoff' s  amputation  of  the  foot. 

always  necessary  in  Pirogoff' s  amputation,  and  may  be  performed  as  a 
preliminary  step. 

Amputation  of  the  I/eg". — Lower  Third. — Circular  and  Modified 
Circular  Methods. — The  place  at  which  the  bones  are  to  be  divided  is 
determined,  and  at  a  point  at  a  distance  below  this  equal  to  two-thirds 
of  the  diameter  of  the  leg  a  circular  incision  is  made,  dividing  the 
skin  and  subcutaneous  tissue.  This  circular  flap  is  dissected  up  and 
rolled  back  upon  itself  to  the  desired  height,  and  another  circular 
incision  carried  through  all  the  soft  parts  to  the  bone.  The  catlin  is 
now  used  to  divide  the  interosseous  membrane  and  the  remaining 
muscular  attachments,  and  the  bones  are  sawed.  A  modification  of 
this  amputation  consists  in  the  addition  of  a  longitudinal  incision 
upward  on  the  anterior  surface  of  the  flap,  to  facilitate  dissection 
(Fig.  107,  a  a). 

Amputation  by  a  Long  Anterior  Flap. — The  incision  begins  on  the 
level  at  which  the  bones  are  to  be  divided,  at  the  internal  surface  of  the 
tibia,  and  passes  downward  in  a  curve  across  the  anterior  surface  and 
upward  to  a  point  in  front  of  the  fibula,  cutting  a  flap  equal  in  length  to 
the  diameter  of  the  leg.  This  flap  includes  all  the  muscles  to  the 
bone.  The  posterior  incision  is  made,  connecting  the  ends  of  the  ante- 
rior one,  and  passes  directly  inward  to  the  bone.  The  bones  are  now 
sawed  at  the  highest  point,  and  the  flap  sutured  over  the  ends,  giving 
a  scar  on  the  posterior  surface.  In  sawing  the  bones,  the  saw-cut  must 
begin  in  the  tibia,  but  be  made  to  engage  the  fibula  as  soon  as  a  groove 
is  cut.  A  double  cut  is  also  recommended,  dividing  the  fibula  slightly 
above  the  tibia ;  and  much  care  must  be  exercised  that  the  prominent 
anterior  edge  of  the  tibia  be  smoothed  off,  to  prevent  injury  to  the  flap 
and  an  uneven  bearing  surface  (Fig.  109,  a). 


AMPUTATIONS. 


355 


Guyon's  Amputation  {Elliptical  Posterior  Flap)  (Fig.  109,  b). — This 
operation  resembles  Syme's  amputation,  and  is,  in  fact,  a  supramal- 
leolar amputation  of  the  ankle.  The  incision  begins  1  inch  above  the 
'front  of  the  articular  surface  of  the  tibia,  and  extends  in  a  curve  in 
front  of  the  malleolus,  on  each  side,  to  just  below 
the  point  of  insertion  of  the  Achilles  tendon,  mak- 
ing a  large  ellipse.  The  flap  is  dissected  up,  con- 
taining the  tendo  Achillis  and  all  the  soft  parts  to 
the  bone,  great  care  being  taken  of  all  the  vessels 
back  of  the  ankle-joint.  The  malleoli  and  artic- 
ular surface  are  then  sawed  off,  as  in  Syme's  opera- 
tion, but  about  1 J  to  2  inches  above  the  joint.  The 
anterior  and  posterior  tibial  and  peroneal  arteries 
will  require  ligature,  and  the  stump  can  be  closed, 
bringing  the  scar  anteriorly,  and  forming  a  good 
bearing  surface  out  of  the  heel-flap  under  the  ends 
of  the  bones.     • 

Middle  Third  of  the  Leg. — Long  Anterior  Flap. 
— At  a  point  1  inch  below  the  level  at  which  the 
bones  are  to  be  divided  an  anterior  flap  is  cut,  equal 
in  breadth  and  length  to  the  diameter  of  the  limb. 
The  two  ends  of  this  incision  are  then  joined  by  a 
short  posterior  flap  cut  by  transfixion  behind  the 
bone  (Fig.    109,  a). 

Long  Posterior  Flap  {Hey-Lee). — The  difficulty 
in  this  amputation  is  in  reducing  the  mass  of  calf- 
muscles  sufficiently  to  avoid  an  unwieldy  flap.  The 
incisions  are  just  the  reverse  of  those  for  an  ante- 
rior flap,  but  the  deep  muscles  of  the  calf  are  re- 
moved by  dividing  them  circularly  at  the  level  of 
the  saw-cut.  The  bones  are  sawed  in  the  same 
manner  as  in  the  lower  third  of  the  leg,  with  ob- 
lique division  of  the  crest  of  the  tibia.  The  scar 
should  lie  anteriorly,  but  may  be  drawn  to  the  end 
of  the  stump  by  the  contraction  of  the  muscles  of 
the  calf. 

Circular  Amputation  with  Skin-flaps  (Fig.  107, 
bb). — The  modification  of  the  circular  method  which  is  best  suited  to 
amputation  in  the  middle  of  the  leg  is  that  by  two  equal  lateral  skin- 
flaps.  These  flaps  are  each  equal  in  length  to  one-half  the  diameter  of 
the  leg,  and  are  marked  out,  beginning  at  a  level  1  inch  lower  than  that 
at  which  the  bones  are  to  be  divided.  The  knife  is  carried  through  the 
skin  and  subcutaneous  tissues  to  the  fascia,  and  the  flaps  thus  formed 
are  dissected  upward  to  their  point  of  union.  The  whole  flap  is  then  dis- 
sected back  to  above  the  level  of  the  saw-cut.  The  muscles  and  soft 
parts  are  now  divided  as  high  up  as  possible  by  circular  sweeps  of  the 
knife  down  to  the  bone.  The  interosseous  ligament  is  perforated,  and 
the  remaining  shreds  of  muscle  severed  with  the  catlin.  A  periosteal 
elevator  is  used  to  push  back  the  periosteum  on  the  tibia  and  fibula 
and  lay  the  bone  bare  for  the  saw.  In  sawing  the  bones  in  this  situa- 
tion the  suggestion  given  above  in  regard  to  removing  the  prominent 


Fig.  107. — a,  Amputa- 
tion of  the  leg  at  the 
"place  of  choice"  by 
circular  incision  ;  5,  am- 
putation of  the  leg  with 
formation  of  two  flaps  ; 
c  c,  supramalleolar  am- 
putation. 


356 


INTERNATIONAL    TEXTBOOK  OF  SURGERY. 


crest  of  the  tibia  is  not  to  be  neglected,  and  a  smooth  surface  free  from 
splinters  and  projecting  fragments  must  be  obtained.  Three  arteries 
will  require  ligature — the  anterior  and  posterior  tibial  and  peroneal — 


FlG.  108. — Amputation  of  the  lower  leg:  a, 
modified  circular  ;  b,  modified  flap  operation. 


Fig.  109. — Amputation  of  the  lower  leg:  a, 
long  anterior  flap;  b,  supramalleolar;  c,  Se- 
dillot's  incision. 


and  the  flaps  may  then  be  united  from  before  backward  to  form  a  scar 
at  the  outer  side  of  the  tibia. 

Upper  Third  of  the  Leg. — Amputation  at  the  place  of  election  was 
practised  extensively  before  the  modern  artificial  leg  had  been  devel- 
oped, because  a  short  stump  was  less  in  the  way  than  a  long  one, 
when  the  knee  was  bent  to  fit  the  peg  leg  then  in  use.  Amputations 
at  this  point  are  still  performed,  however,  when  injury  or  disease  for- 
bids a  more  conservative  operation,  and  the  circular  method  or  one  of 
the  following  flap-operations  may  be  adopted  (Fig.  107,  ad). 

Modified  Flap  Operation  of  Bell. — Two  equal  flaps  are  marked  out 
upon  the  skin,  each  being,  after  retraction,  about  equal  in  length  to 
one-half  the  diameter  of  the   leg,  their  bases  being  at  the  level  of 


AMPUTATIONS.  357 

the  intended  division  of  the  bone,  the  incision  starting  in  front  at  the 
inner  border  of  the  tibia,  and  behind  at  a  point  diametrically  opposite. 
These  flaps  include  the  skin  and  subcutaneous  tissue,  and  are  dissected 
back  beyond  their  point  of  union.  The  muscles  are  divided  in  the 
manner  of  the  circular  operation,  the  knife  being  carried  a  little  higher 
in  front  than  behind.  The  bones  are  then  sawed  through,  and  the 
vessels  tied  in  the  usual  manner. 

Large  External  Flap  (Fig.  109,  e). — This  amputation  may  be  per- 
formed by  transfixion  (Sedillot),  or  the  flap  may  be  dissected  from 
without  inward  (Faraboeuf ).  The  flap  begins  at  the  level  at  which  the 
bones  are  to  be  divided.  The  knife  enters  over  the  anterior  surface  of 
the  tibia,  marks  out  a  long  U-shaped  flap,  upon  the  external  surface, 
equal  in  length  to  the  diameter  of  the  leg,  and  ends  at  a  point  opposite 
to  its  point  of  entrance.  This  flap  is  dissected  up,  and  contains  all  of 
the  soft  parts  above  the  bone.  The  short  posterior  flap  may  be  cut  either 
by  transfixion  or  dissected  from  without  inward,  and  the  two  flaps  re- 
tracted to  allow  division  of  the  interosseous  membrane  and  the  applica- 
tion of  the  saw.  The  fibula  may  be  sawed  a  little  higher  than  the  tibia 
in  all  of  the  amputations  in  this  region,  in  order  to  provide  a  more 
evenly  shaped  stump,  and  the  crest  of  the  tibia  is  to  be  removed  as  a 
matter  of  routine.  After  ligature  of  the  three  main  vessels  the  external 
flap  is  brought  over  the  end  of  the  bone  and  united  to  the  shorter 
internal  flap,  giving  the  scar  to  the  inner  side  of  the  stump.  This  is 
considered  by  many  surgeons  to  be  the  best  method  for  amputation  in 
this  region. 

Amputation  in  the  Lower  Third. — This  is  attended  by  much  less 
shock  than  are  amputations  above  this  point,  and  is  much  to  be  pre- 
ferred when  the  nature  of  the  injury  or  disease  does  not  forbid.  The 
selection  of  a  method  in  all  amputations  of  the  leg  must  depend  upon 
the  personal  choice  and  practice  of  the  surgeon  and  the  demands  of 
the  individual  case.  As  a  general  rule,  the  circular  method,  or  one 
of  its  modifications,  will  be  found  most  universally  applicable,  and  the 
operation  by  far  the  most  easy  of  execution. 

Amputation  at  the  Knee. — Disarticulation. — Long  Anterior 
Flap  (Fig.  1 10,  a). — An  incision  is  begun  at  the  posterior  and  inferior 
margin  of  the  femoral  condyle,  and  is  carried  downward,  across  the 
front  of  the  tibia,  5  inches  below  the  patella,  and  back  to  the  cor- 
responding point  on  the  other  side.  This  flap  includes  skin  and  sub- 
cutaneous tissue  up  to  the  ligamentum  patellae,  which  is  then  divided 
and  left  in  the  flap.  The  joint  is  opened,  its  ligaments  divided,  and  the 
amputation  completed  by  an  incision  from  within  outward  to  the  pos- 
terior surface  of  the  limb  (Fig.  1 10). 

Lateral  Flaps  {Stephen  Smith). — Two  equal  lateral  skin-flaps  are 
cut,  their  bases  extending  posteriorly  to  the  middle  line  of  the  joint, 
and  anteriorly  to  I  inch  below  the  tubercle  of  the  tibia.  Each  of  these 
flaps  is  dissected  up,  and  the  joint  is  opened  and  its  ligaments  divided 
from  in  front.  The  posterior  ligaments  and  muscles  are  then  cut 
through  and  the  disarticulation  is  complete.  The  patella  and  the 
semilunar  cartilages  should  remain  in  the  stump.  This  method  gives 
an  excellent  bearing  surface  for  the  stump,  the  scar  retracting  between 
the  condyles  of  the  femur. 


358  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

Amputation  Through  the  Condyles. — Oval  Method. — This  incision 
is  practicable  either  for  disarticulation  (Baudens)  or  for  amputation 
through  the  condyles.  An  oval  cut  is  made  around  the  leg,  3  inches 
below  the  patella  in  front,  and  on  a  level  with  its  lower  border  behind. 
The  skin  and  subcutaneous  tissues  are  dissected  up  as  in  the  circular 
operation,  and  either  disarticulation  is  performed  as  already  described, 
or  the  bone  is  sawed  above  the  articular  surface.  The  patella  may  be 
left  in  the  anterior  part  of  the  flap,  or  it  may  be  dissected  out  and 
removed  with  the  tibia. 

Carden's  Amputation  {Anterior  Flap)  (Fig.  110,  b). — An  incision 
begins  over  the  posterior  portion  of  the  femoral  condyle  1  inch  above 
the  joint,  and  extends  in  a  broad  sweep  across  the  front  of  the  knee, 
about  half-way  down  the  ligamentum  patellae,  and  up  again  to  a  point 
on  the  other  side  corresponding  to  its  point  of  origin.  This  incision 
extends  through  skin  and  subcutaneous  tissue  only,  and  the  flap  is 
dissected  up  to  above  the  patella.  The  two  ends  of  the  first  incision 
are  now  united  by  a  short  curved  incision  across  the  back  of  the  joint. 
After  retracting  the  anterior  flap,  the  quadriceps  tendon  is  divided,  the 
joint  opened  and  disarticulated,  and  the  posterior  muscles  severed 
from  within  outward.  The  articular  surface  of  the  femur  is  now  sawed 
off,  and  the  operation  is  completed  by  ligature  of  the  popliteal  artery 
and  its  articular  branches,  and  suture  of  the  wound  from  before  back- 
ward. 

Gritti's  Amputation  (Fig.  1 1 1). — By  this  method  the  patella  is  used 
to  cap  the  stump  of  the  femur,  and  advantage  is  taken  of  the  pre- 
patellar bursa  to  provide  a  loosely  moving  covering  to  the  end  of  the 
stump.  The  general  steps  are  the  same  as  in  Carden's  operation,  the 
long  anterior  flap  being  more  rectangular  and  its  base  slightly  higher 
on  the  front  of  the  femur.  The  anterior  flap  is  dissected  up,  and  the 
ligamentum  patellae  divided  at  its  insertion  and  retained  in  the  flap. 
Disarticulation  follows  as  in  Carden's  operation,  and  the  articular  sur- 
face and  condyles  of  the  femur  are  sawed  through  at  a  level  above 
their  most  prominent  part.  The  sawing,  of  the  patella  is  the  most  dif- 
ficult part  of  this  operation,  and  is  best  accomplished  by  a  small  meta- 
carpal saw  while  the  bone  is  held  firmly  with  lion-forceps.  After  the 
articular  surface  has  been  removed  and  the  necessary  blood-vessels 
tied,  the  patella  is  drawn  down  over  the  end  of  the  femur  and  held 
with  pins  or  sutures.  This  operation  is  an  imitation  of  Pirogoff  s 
osteoplastic  ankle-amputation,  but  does  not  appear  to  have  attained 
the  popularity  of  Pirogoff's,  although  not  essentially  differing  from  it 
in  any  way.  The  technical  difficulties,  however,  in  its  performance 
are  considerable,  and  a  tendency  has  been  noted  to  the  drawing  for- 
ward and  upward  and  displacing  of  the  patella  by  the  strong  quadri- 
ceps muscle.  This  may  be  obviated  by  a  sufficiently  high  division  of 
the  femur,  or  by  section  of  the  quadriceps  tendon  in  whole  or  in  part. 
Amputation  of  the  Thigh. — Here  the  conditions  are  similar  to 
those  in  the  upper  arm,  there  being  one  bone  well  surrounded  by 
muscle,  except  at  the  lower  end,  so  that  almost  any  recognized  method 
of  amputation  may  be  carried  out.  There  are  many  operations,  differ- 
ing slightly,  described  by  and  named  after  different  men.  None  will 
be  mentioned  except  those  commonly  used.     Amputation  may  be  per- 


AMPUTA  TIONS. 


359 


formed  anywhere  from  the  trochanter  to  the  condyles,  but  is  gener- 
ally done  at  some  part  of  the  middle  third.  The  operations  consist 
of  the  flap  and  the  circular  methods,  with  a  modification  of  each.  As 
the  skin  and  muscles  on  the  posterior  and  inner  side  have  the  greater 
power  of  retraction,  the  operator  must  correct  this  by  making  his 
incision  lower  at  these  points.     The  number  and  size  of  the  vessels  to 


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Fig.  iio. — Disarticulation  of  knee:  an,  long  flap;  FIG.  in. — External  lateral  view  of 

b  b,  after  Gritti  and  Carden.  thigh:  a,  Gritti's  incision  for  disarticu- 

lation of  knee  ;  bb,  Sedillot's  amputation 
of  thigh  ;  c,  double  flap  method  in  lower 
third;  dd,  external  racket  incision  for 
hip-joint. 

be  tied  will  vary  with  the  height  of  the  section.  They  include  the  fem- 
oral, profunda,  anastomotica  magna,  perforating  and  muscular  branches. 
Flap  Operations. — In  the  anteroposterior  method  the  flaps  are 
made  by  transfixion,  the  posterior  being  the  longer,  to  allow  for  the 
greater  retraction  which  takes  place.  The  main  artery  will  be  in 
the  anterior  or  posterior  flap  according  as  the  section  is  high  or  low. 
In  the  lateral  flap  operation  (Vermale)  the  flaps  are  also  cut  by  trans- 


360  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

fixion  and  are  of  equal   length.     This  operation  is   not  much  done  at 
present,  and  is  not  a  good  one  for  the  lower  part  of  the  thigh. 

Long  Anterior  Flaps  (Fig.  ill,  c). — This  method  gives  very  good 
results.  The  flaps  are  marked  out  first  on  the  skin  as  follows :  An 
anterior  flap  is  cut,  with  its  base  about  half  the  circumference  of  the 
limb,  and  its  "  length  equal  to  one  diameter  and  a  half  of  the  limb  at 
the  saw-line "  (Treves).  A  short  posterior  flap  is  also  marked  out. 
In  this  case  the  anterior  flap  is  best  cut  from  without  inward,  following 
the  line  in  the  skin,  taking  care  that  it  be  not  too  thick.  The  posterior 
flap  may  be  cut  by  transfixion.  The  bone  is  then  exposed  and  sawed 
through.  In  sawing  through  the  femur,  in  all  cases  the  edges  should 
be  smoothed  by  bevelling  with  a  saw  or  chisel. 

The  modification  known  as  Sedillofs  operation  differs  from  this  in  that  there  is  no  pos- 
terior flap,   the  structures  being  cut  straight  to  the  bone   (Fig.  Ill,  b). 

The  Modified  Circular  (Fig.  112). — An  oblique  circular  incision  is 
made  in  the  skin,  beginning  at  the   outside  of  the  thigh,  and  carried 


FIG.  112. — Amputation  of  the  thigh  with  oval  incision. 

inward  about  the  limb  to  the  starting-point,  with  a  downward  slant 
sufficient  to  allow  for  the  posterior  retraction.  According  to  Faraboeuf, 
the  incision  on  the  anterior  surface  should  be  at  a  distance  from  the 
proposed  section  equal  to  one-quarter  the  circumference  of  the  thigh 
at  that  point,  and  that  on  the  posterior  equal  to  about  one-third  of  the 
same.  The  skin  is  loosened  and  held  back  evenly.  The  muscles 
are  then  divided  obliquely  in  layers  parallel  to  the  skin-incision,  each 
layer  being  allowed  to  retract.  The  muscles  are  then  held  back  and 
the  bone  is  sawed. 

Another  very  excellent  method,  described  by  Wyeth,  consists  of 
an  oblique  circular  skin-incision  with  a  short  incision  on  the  outer 
surface  at  right  angles  to  the  first,  which  is  practically  a  racket  incision 
with  a  short  handle.  This  enables  the  operator  to  turn  the  skin  back 
with  greater  ease.     The  rest  of  the  operation  is  the  same. 

In  Syme's  modification  two  extra  incisions  are  made,  thus  forming 
short  rectangular  anterior  and  posterior  skin-flaps. 

Amputation  at  the  Hip-joint. — This  operation  is  by  far  the 
most  formidable  of  all  the  amputations,  and  was  for  a  long  time 
deemed   unjustifiable;  but  modern  technic  has  brought  it  under  the 


A  MPUTA  TIONS.  36 1 

head  of  recognized  operations,  and  it  may  be  done  successfully  in 
many  cases.  It  is  indicated  when  amputation  cannot  be  done  below 
the  great  trochanter.  The  principal  dangers  are  hemorrhage  and 
shock,  the  latter  being  somewhat  dependent  upon  the  former.  The 
prevention  of  shock  is  elsewhere  considered.  There  have  been  many 
means  suggested  for  the  control  of  hemorrhage  :  manually,  by  digital 
compression  of  the  aorta,  the  external  iliac,  the  common  iliac  (by  inci- 
sion), and  the  femoral ;  mechanically,  by  means  of  various  apparatus, 
as  Lister's  aortic  tourniquet,  which  is  not  now  used,  and  by  Davy's 
ingenious  but  unreliable  method  of  applying  pressure  to  the  common 
iliac  by  means  of  a  lever  introduced  into  the  rectum.  Some  operators 
prefer  to  ligate  the  femoral  or  common  iliac  first,  or  to  tie  each  vessel 
as  it  appears  in  the  wound.  As  the  most  troublesome  bleeding  comes 
from  the  branches  of  the  internal  iliac,  some  means  should  be  adopted 
that  will  occlude  them.  The  elastic  tourniquet  is  the  best  mechanical 
aid  we  have  for  this  purpose.  The  most  satisfactory  application  is 
after  the  method  of  Wyeth  or  Trendelenburg,  who  first  transfix  the 
thigh  with  steel  pins,  Wyeth  making  use  of  two,  and  Trendelenburg 
one.  The  tourniquet  is  then  tightly  applied  above  them,  and  cannot 
slip. 

The  Esmarch  elastic  bandage  should  be  applied  in  all  possible  cases, 
with  the  limb  in  an  elevated  position.  The  conditions  contra-indicating 
its  use  are  :  sepsis,  when  some  of  the  infected  material  might  be  forced 
into  the  sound  portion  of  the  limb  ;  certain  tumors  which  would  obstruct 
mechanically ;  and  in  cases  of  extreme  crush  with  pulpefaction  follow- 
ing any  severe  accident. 

The  Anterior  Racket  or  Oval  Method  (Fig.  114,  re). — In  this  pro- 
cedure hemorrhage  is  dealt  with  by  ligaturing  the  femoral  first,  and  the 
other  vessels  as  they  are  met  with  during  the  removal  of  the  limb. 
No  tourniquet  is  used,  but  the  elastic  bandage  of  Esmarch  should  be 
applied.  A  racket  incision  is  made  in  the  skin,  down  to  the  muscles, 
as  follows  :  The  straight  part  of  the  incision  begins  just  below  Pou- 
part's  ligament,  over  the  origin  of  the  femoral,  and  follows  the  course 
of  that  vessel  for  about  3  inches.  The  cut  then  curves  obliquely 
inward  and  downward,  passing  about  the  limb,  and  being  brought  up 
on  the  outer  surface  just  below  the  great  trochanter,  upward,  to  meet 
itself  at  the  point  of  separation  from  the  vertical  incision.  The  next 
step  is  the  ligation  of  the  great  vessels.  They  are  exposed,  the  artery 
and  vein  being  separately  tied  in  two  places  and  divided.  Now  the 
section  of  the  muscles  should  begin.  In  the  outer  flap  are  the  sar- 
torius,  rectus,  and  tensor  vaginas  femoris.  These  are  divided  ;  then 
the  gluteus  maximus.  Under  this  is  found  the  trochanter.  The  limb 
is  rotated  inward  to  put  the  short  rotators  on  the  stretch,  and  the  latter 
then  divided.  Now  the  thigh  is  rotated  outward,  and  the  psoas  and 
all  muscles  on  the  inner  side  are  cut.  The  articulation  can  now  be 
opened,  and  the  femur  disarticulated  by  going  backward  through  the 
joint  and  dividing  the  muscles  at  the  posterior  part. 

The  Modified  Oval  or  External  Racket  Incision. — The  skin-incision 
is  made  on  the  outer  aspect  of  the  limb ;  the  straight  portion  is  begun 
about  2  inches  above  the  trochanter  and  continued  downward  6  or  7 
inches.     It  is  then  carried  obliquely  downward  across  the  anterior  sur- 


\62 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


face,  transversely  across  the  inner,  some  distance  below  the  end  of  the 
straight  incision,  and  upward  on  the  posterior  surface  to  the  lower  end 
of  the  first  cut  (Fig.  113).  The  skin  is  now  loosened  all  around  and 
held  back  ;  the  anterior  muscles  being  cut,  all  the  muscles  are  freed 
from  the  trochanter  and  the  upper  end  of  the  femur.  The  capsule  of 
the  joint  is  cut  and  the  head  disarticulated  outward.  The  adductors 
and  other  muscles  on  the  inner  side  are  divided  and  the  operation 
completed.     All  vessels  are  then  tied. 

The  Furneaux-Jordan  method  is  a  modification  of  this  one.  The 
operation  as  described  by  him  consists  of  a  straight  incision  over  the 
trochanter,  connecting  with  a  circular  one  at  some  lower  level.     The 


Fig.   113. — Disarticulation   at   the   hip-joint 
with  external  racket  incision. 


FlG.  114. — Amputation  at  the  hip-joint: 
a  a,  by  anterior  flap;  bb,  modified  circular 
method  (Furneaux-Jordan);  c,  anterior 
racket  incision. 


bone  is  enucleated,  and  the   limb  removed  by  a  circular  division  of  the 
muscles  (Fig.  114,  b  b). 

The  Anterior  Flap  Method. — This  is  the  operation  by  transfixion, 
and  was  much  used  in  pre-anesthetic  days  because  of  the  extreme 
rapidity  with  which  it  could  be  performed.  It  is  still  done  after  cer- 
tain cases  of  injury,  for  the  same  reason.  The  femoral  is  controlled 
by  direct  pressure  by  an  assistant.  To  cut  the  anterior  flap,  the 
thigh  should  be  flexed,  and  a  long  knife  introduced  half-way  between 
the  anterior  superior  spine  of  the  ilium  and  the  great  trochanter, 
passed  inward  in  front  of  the  joint,  opening  the  capsule  if  possible,  to 
emerge  on  the  inner  side  an  inch  below  and  anterior  to  the  tuberosity 
of  the  ischium  (Fig.  1 14,  ad).  A  flap  is  now  cut  from  within  outward 
and  turned  back,  the  femur  being  disarticulated  by  enlarging  the  open- 
ing in  the  capsule  and  depressing  the  knee.  The  thigh  is  rotated 
inward,  and  the  short  rotators  divided ;  then  the  posterior  flap  is  cut 
by  carrying  the  knife  behind  the  head  of  the  bone  and  bringing  it 
downward  and  outward.     All  vessels  are  to  be  caught  and  tied. 


AMPUTATIONS.  363 

Esmarch's  Method. — This  operation  has  two  steps,  a  circular  thigh 
amputation  6  inches  below  the  trochanter,  followed  by  the  removal  of 
the  remaining  portion  of  the  femur  through  an  external  lateral  inci- 
sion. 

Serin's  Method. — This  is  a  complicated  procedure  by  which  the 
head  of  the  bone  is  enucleated  and  brought  out  through  an  external 
incision.  A  rubber  tourniquet  is  passed  into  the  wound,  and  brought 
out  through  a  small  opening  on  the  inner  surface.  The  tourniquet 
is  cut,  and  one  part  tied  about  the  thigh  in  front,  the  other  carried 
behind,  crossed,  and  tied  in  front  higher  than  the  first.  Flaps  are  then 
fashioned,  and  the  limb  removed  by  a  circular  cut. 

The  Circular  Method  (Fig.  114,  bb). — No  special  description  of 
this  is  needed.  A  circular  skin-incision  is  made  6  inches  below  the 
anterior  superior  spine  of  the  ilium.  The  muscles  are  divided  down 
to  the  bone  in  the  same  manner  at  a  higher  level.  The  joint  is  then 
opened. 

Wyeth's  Bloodless  Method. — This  operation  is  without  doubt  the 
simplest,  safest,  and  best  method  we  have  for  hip-joint  amputation.  It 
can  be  done  quickly,  and  there  is  practically  no  blood  lost.  The 
technic  may  be  briefly  outlined  from  the  description  given  by  Wyeth,1 
as  follows  :  The  patient  is  placed  with  the  sacrum  upon  the  corner  of 
the  operating-table.  The  limb  to  be  amputated  should  be  emptied  of 
blood  by  applying  the  elastic  bandage,  except  where  contra-indicated, 
as  before  noted.  Two  steel  needles  are  required,  T3^  inch  thick  and  10 
inches  long.  Their  introduction  is  described  by  Wyeth  in  the  follow- 
ing manner :  "  One  pin  enters  \  inch  below  the  anterior  superior  spine 
of  the  ilium  and  slightly  to  the  inside  of  this  prominence,  and  is  made 
to  traverse  superficially  for  about  3  inches  the  muscles  and  fasciae  on 
the  other  side  of  the  hip,  emerging  on  a  level  with  the  point  of 
entrance.  The  point  of  the  second  needle  is  thrust  through  the  skin 
and  tendon  of  origin  of  the  adductor  longus  muscle  \  inch  below  the 
crotch,  the  point  emerging  an  inch  below  the  tuber  ischii."  The  points 
of  the  pins  are  shielded  by  corks,  and  the  tourniquet  wound  five  or 
six  times  very  tightly  about  the  limb  above  the  pins.  The  Esmarch 
bandage  is  now  removed.  A  circular  incision  is  made  in  the  skin 
about  6  inches  below  the  tourniquet,  and  a  longitudinal  cut  from  the 
tourniquet,  in  the  line  of  the  trochanter,  to  join  it.  The  integuments 
are  dissected  back,  and  the  soft  parts  divided  down  to  the  bone  by  a 
circular  sweep  even  with  the  lesser  trochanter.  The  larger  vessels  are 
now  tied.  All  muscular  insertions  should  now  be  separated  from 
the  trochanters  and  upper  part  of  the  femur.  This  brings  the  operator 
down  to  the  capsular  ligament,  which  is  cut  through,  and  the  limb  dis- 
articulated by  manipulation  after  division  of  the  ligamentum  teres. 
Nothing  now  remains  to  be  done  but  to  tie  the  other  vessels  and 
close  the  wound  by  sutures.  The  vessels  to  be  tied  at  this  stage  are 
the  sciatic  and  obturator  and  the  descending  branches  of  the  external 
and  internal  circumflex  arteries.  Wyeth  recommends  suturing  the 
stumps  of  the  divided  muscles  with  catgut,  in  order  to  stop  the  oozing 
by  quilting  large  surfaces  of  muscle  together. 

1  A  complete  account  of  the  operation  may  be  found  in  Wyeth's  article  in  the  Annals 
of  Surgery,  1897,  vol.  25,  p.  129. 


364  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

EXCISION  OF  BONES  AND  JOINTS. 

The  term  "  excision  of  a  joint "  means  the  removal  of  one  or  all 
the  extremities  of  the  bones  which  enter  into  the  formation  of  any 
given  joint.  When  only  one  extremity  is  excised,  the  excision  is  "  par- 
tial ;"  when  all  the  extremities  are  excised,  the  excision  is  "  complete." 

"  Resection  "  means  the  removal  of  the  entire  thickness  of  a  bone. 

Joints  are  excised  for  the  relief  of  various  conditions,  such  as  dis- 
ease, especially  when  well  advanced,  trauma,  old  unreduced  disloca- 
tions, ankylosis  in  faulty  position  ;  also  for  the  purpose  of  obtaining 
motion.     Excision  may  save  the  patient  from  an  amputation. 

Certain  general  principles  should  govern  all  excisions.  All  diseased 
tissue  should  be  carefully  removed,  whether  it  be  bone  or  soft  parts, 
although  the  utility  of  most  joints  will  depend  upon  the  preservation 
of  tendons,  and  usually  upon  as  little  sacrifice  of  bone-tissue  as  pos- 
sible. In  children,  extensive  resection  will  prevent  the  normal  growth 
of  the  limb.  In  all  cases  a  good  position  of  the  limb  will  depend 
upon  the  care  with  which  the  excision  is  conducted,  but  in  the  knee- 
joint  extraordinary  care  is  necessary  in  order  to  obtain  a  straight  leg. 

Excisions  call  for  strict  asepsis,  much  skill  in  the  application  of 
splints,  and  good  judgment  in  managing  the  convalescence.  All  tour- 
niquets should  be  avoided  if  possible. 

The  results  following  excision  depend  upon  the  cause  for  which  the 
operation  is  undertaken,  the  age  and  general  condition  of  the  patient, 
as  well  as  the  mode  of  operation  and  care  received  during  conva- 
lescence. 

It  is  not  to  be  expected  that  the  function  of  a  joint  will  be  com- 
pletely restored,  but  the  nearest  approach  has  been  obtained  by  the  so- 
called  "  subperiosteal  method,"  to  be  described  later.  In  general,  how- 
ever, the  results  derived  from  excision  are  good,  and  the  mortality  is 
not  high. 

Excision  of  the  Shoulder-joint. —  Von  Langenbeck's  Method. — 
The  shoulder-joint  is  a  lax  joint  formed  by  the  articulation  of  the  head 
of  the  humerus  with  the  glenoid  fossa  of  the  scapula.  A  loose  cap- 
sule, re-enforced  by  several  muscles,  keeps  these  bones  more  or  less  in 
approximation.  Excision  of  the  shoulder-joint  is  usually  "  partial," 
because  commonly  only  the  head  of  the  humerus  is  removed.  The 
coracoid  and  acromion  processes  and  the  greater  and  lesser  tuberosities 
are  important  landmarks.  The  contour  of  the  deltoid  muscle,  the 
direction  of  its  fibers,  and  the  posterior  position  of  the  circumflex  artery 
and  nerve  are  important  considerations. 

There  are  various  methods  of  approaching  and  excising  this  joint. 
All  flap  operations  which  sever  the  deltoid  fibers  are  no  longer  in  gen- 
eral use,  and  the  joint  is  best  approached  by  means  of  an  incision 
roughly  parallel  with  these  fibers.  Having  reached  the  capsule,  the 
head  of  the  humerus  may  be  exposed  and  excised  by  means  of  the 
open  or  the  subperiosteal  method. 

The  patient  is  placed  on  his  back  with  the  shoulders  somewhat  ele- 
vated and  near  the  edge  of  the  operating-table,  and  the  flexed  arm  is 
controlled  by  an  assistant.  The  capsule  may  be  exposed  by  one  or 
two  incisions. 


EXCISION  OF  BONES  AND  JOINTS. 


365 


Von  Langenbeck's  incision  (Fig.  115,  B)  starts  at  a  point  just  exter- 
nal to  the  acromioclavicular  articulation,  and  is  carried  directly  down- 
ward for  about  4  inches,  passing  through  the  thickness  of  the  deltoid 
so  as  to  expose  the  capsule  and  the  greater  tuberosity,  the  arm  having 
been  rotated  somewhat  inward. 

Oilier 's  incision  (Fig.  115,^)  is  anterior  to  this  one,  and  commences 
at  a  point  near  the  tip  of  the  coracoid  process,  follows  the  direction 
of  the  fibers  of  the  deltoid  downward  and  backward  for  about  4  inches, 


Fig.  115. — Excision  of  the  shoulder-joint:  A,  Ollier's  method;  B,  von  Langenbeck's  incision, 

C,  Hueter's  incision. 

and  is  also  carried  boldly  down  to  the  capsule  and  greater  tuberosity 
of  the  humerus.     The  latter  incision  is  preferable. 

Exposing  the  Head  of  the  Humerus. — The  long  head  of  the  biceps 
is  sought  for,  and  should  always  be  preserved.  The  capsule  is 
opened  by  an  incision  external  and  parallel  to  this  tendon,  made 
from  below  upward.  The  operator  must  now  decide  for  himself  as  to 
whether  he  will  use  the  open  or  the  subperiosteal  method.  The  former 
is  the  more  common  and  easier  procedure  ;  the  latter  is  more  difficult 
and  less  frequently  practicable,  but  gives  the  best  results.  In  per- 
forming the  open  method,  the  edges  of  the  wound  are  retracted,  the 
biceps  tendon  drawn  inward,  and  as  the  assistant  adducts  and  rotates 
the  humerus  the  insertion  of  the  capsule,  together  with  the  tendons  of 
the  supraspinatus,  infraspinatus,  and  teres  minor  muscles,  is  severed. 
The  biceps  tendon  is  then  retracted  externally  and  rotated  in  the  oppo- 
site direction,  so  as  to  expose  the  subscapularis  tendon,  which  is  to  be 
severed  together  with  this  portion  of  the  capsule.  The  head  of  the 
bone  can  now  be  forced  up  out  of  the  capsule,  the  remaining  portion 
of  which  can  be  cut  across  if  necessary,  and  the  head  of  the  bone  be 


366 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


excised  by  means  of  the  saw.  This  method  severs  the  scapular  mus- 
cles from  the  humerus.  It  is  well  not  to  remove  any  more  of  the  bone 
than  is  necessary,  particularly  in  children. 

The  object  of  the  subperiosteal  method  is  to  preserve  the  attach- 
ment of  the  scapular  muscles.  The  capsule  is  exposed  and  opened  as 
above,  and  the  biceps  tendon  retracted  in  a  similar  manner.  By  means 
of  a  periosteum-elevator,  as  the  arm  is  rotated  the  periosteum,  capsule, 
and  tendons  of  the  scapular  muscles  are  separated  from  the  bone  in  one 
continuous  layer,  so  as  to  expose  the  head  of  the  humerus  and  more  or 
less  of  the  tuberosities.  The  bone  is  then  forced  out  of  the  joint  and 
excised. 

Transverse  Incision  {Nelaton). — In  certain  instances  it  will  be  neces- 
sary to  remove  a  portion  of  the  glenoid  fossa  and  to  supplement  the 
original  incision  by  a  transverse  one. 

Excision  of  the  Blbow-joint. — Excision  of  the  elbow-joint 
should  be  "  complete,"  for  a  "  partial  "  excision  is  more  liable  to  be 
followed  by  ankylosis — a  result  to  be  avoided  at 
the  elbow.  Nevertheless,  care  must  be  exercised 
in  order  that  too  much  bone  be  not  excised,  for 
this  may  leave  a  loose  and  consequently  inefficient 
joint. 

The  bony  landmarks  consist  of  the  internal 
and  external  condyles  and  intervening  articular 
surface,  the  coronoid  and  olecranon  processes, 
and  the  head  of  the  radius.  The  other  structures 
to  be  observed  are  the  internal  and  external  late- 
ral ligaments,  the  ulnar  and  posterior  interosseous 
nerves,  and  the  tendons  of  the  triceps,  biceps,  and 
brachialis  anticus  muscles.  These  two  latter  ten- 
dons should  never  be  severed.  There  is  danger 
of  severing  the  ulnar  nerve.  The  variety  of  oper- 
ation which  preserves  the  integrity  of  the  most 
ligaments,  tendons,  and  periosteum  is  the  most 
satisfactory.  The  operation  should  consequently 
be  as  subperiosteal  as  possible. 

The  posterior  longitudinal  incision  is  the 
one  usually  employed  (von  Langenbeck,  Fig. 
116,  a).  The  arm  is  flexed  and  held  with  the 
humerus  nearly  vertical,  and  a  posterior  longi- 
tudinal incision  about  4  inches  long  is  made  so 
that  its  center  is  at  the  top  of  the  olecranon 
process.  This  incision  is  carried  directly  to  the 
bone,  so  as  to  bisect  the  triceps  tendon  and  the 
posterior  ligament.  The  next  step  consists  in 
exposing  the  lower  extremity  of  the  humerus  by 
removing  periosteum,  ligaments,  and  tendons  in 
as  continuous  a  layer  as  possible.  This  is  best 
done  with  the  elevator,  using  the  knife  sparingly. 
The  inner  half  of  the  triceps  tendon  is  first  retracted,  and  then  the 
internal  condyle  exposed,  care  being  exercised  not  to  injure  the  ulnar 
nerve.     Then  the  external  condyle  is  similarly  denuded,  and  the  soft 


FlG.  116. — Excision  of 
the  elbow:  a  a,  von  Lan- 
genbeck's  incision  ;  bb,  Ol 
lier's  incision. 


EXCISION  OF  BONES  AND  JOINTS.  367 

parts  retracted  from  the  exposed  bone.  The  extremity  of  the  humerus 
is  now  grasped  with  lion  forceps  and  sawed  across  transversely  just 
above  the  condyles.  The  forearm  is  now  raised  vertically,  so  as  to 
expose  the  ends  of  the  radius  and  ulna,  which  are  to  be  freed  a  little, 
and  then  sawed  transversely  so  as  to  remove  a  thin  button  from  the 
radius. 

The  wound  may  be  closed  or  not,  according  to  the  judgment  of 
the  surgeon,  and  should  be  placed  upon  a  splint  at  an  angle  somewhat 
greater  than  a  right  angle,  with  the  extremities  of  the  bones  not  in 
approximation.  Ankylosis  is  more  to  be  feared  in  children.  The 
fingers  and  wrist  should  be  free  and  allowed  to  move. 

In  Ollier's  method  the  joint  is  approached  laterally,  one  object 
being  not  to  sacrifice  the  triceps  tendon.  A  cutaneous  incision  is  made 
vertically  along  the  interval  between  the  triceps  and  supinator  longus 
muscles  for  about  2  inches  above  the  joint-line  (Fig.  116,  b),  crossing 
the  condyle  below  toward  the  olecranon  process,  along  which  it  con- 
tinues for  an  inch  or  more.  A  short  vertical  incision  is  made  over  the 
internal  condyle,  through  which  the  internal  lateral  ligament  is  severed. 
By  means  of  these  incisions  the  bones  are  carefully  denuded  and 
excised  as  above  ;  but  this  method  is  less  practicable  than  the  former. 

The  object  of  all  elbow-excisions  is  the  production  of  a  healthy, 
movable  joint.  They  are  commonly  performed  for  advanced  cases  of 
bone-  and  joint-disease,  in  which  case  both  the  bone  and  the  soft 
parts  must  often  be  extensively  sacrificed. 

Excision  of  an  Ankylosed  Elbow. — An  elbow  is  frequently  anky- 
losed  in  an  awkward  position,  and  although  it  does  not  present  any 
active  pathological  process  nor  give  rise  to  any  subjective  symptoms, 
nevertheless  such  an  elbow  is  not  very  useful,  on  account  of  the  limita- 
tion of  motion.  The  results  of  excision  in  such  cases  are  very  satis- 
factory. 

The  joint  may  be  exposed  by  either  the  posterior  or  the  lateral 
incisions.  On  account  of  the  absence  of  pathological  processes,  it  is 
necessary  to  sacrifice  bone-tissue  only,  and  the  operation  can  be  made 
as  near  the  subperiosteal  type  as  is  possible.  The  incisions  are  to  be 
carried  as  near  the  bone  as  possible,  severing  the  capsule.  With  the 
periosteum-elevator  one  condyle  is  to  be  exposed,  and  then  the  other, 
working  carefully  from  within  the  joint,  and  removing  periosteum,  liga- 
ments, and  all  muscle-tendons  in  one  continuous  layer.  This  is  often  a 
difficult  task  on  account  of  the  irregularity  of  the  bones.  The  greatest 
care  should  always  be  exercised  to  prevent  injury  to  the  ulnar  nerve. 
When  sufficient  bone  has  been  exposed,  it  may  be  removed  by  means 
of  the  saw  or  bone-forceps,  first  treating  the  humerus,  and  then  the 
radius  and  ulna. 

The  after-treatment,  as  usual,  consists  in  applying  a  splint  which 
fixes  the  forearm  at  an  angle  of  about  135  degrees,  preventing  a  back- 
ward dislocation  and  securing  absolute  approximation  of  the  fragments. 
Passive  movements  of  all  parts  should  be  resorted  to  earl)-,  and  the  arm 
can  soon  be  flexed  to  a  right  angle. 

Reduction  of  Old  Unreduced  Backward  Dislocations  of  the 
Elbow  by  Operative  Measures.— In  this  dislocation  the  inferior  sur- 
face of  the  coronoid  process  of  the  ulna  is  carried  behind  and  above  the 


368  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

trochlear  surface  of  the  humerus,  and  the  apex  of  the  process  tends  to 
enter  the  olecranon  fossa.  New  fibrous  bands  hold  the  bones  in  this 
abnormal  position,  and  in  time  a  new  socket  may  be  formed.  Operative 
measures  should  be  directed  toward  severing  these  bands,  overcoming 
all  adhesions,  reducing  the  bones  to  their  original  positions,  and  main- 
taining them  by  means  of  apparatus. 

The  first  incision  is  made  over  the  external  supracondyloid  ridge, 
extending  down  to  the  condyle,  and  thence  downward  and  inward, 
between  the  radius  and  ulna,  so  as  to  avoid  the  extensor  group  of  mus- 
cles, and  should  terminate  on  the  ulna.  Through  this  incision  all  new 
bone-formation  should  be  chiselled  away,  fibrous  bands  severed,  and  the 
sigmoid  fossa  cleared  of  all  tissue.  A  curved  incision  is  to  be  made 
over  the  internal  condyle,  the  ulnar  nerve  isolated,  and  all  fibrous  bands 
divided.  The  parts  are  to  be  manipulated  until  perfectly  free,  the  bones 
to  be  replaced,  the  wound  closed,  and  the  parts  to  be  immobilized  with 
an  internal  angular  splint. 

The  arm  must  be  watched  carefully,  in  order  to  avoid  a  recurrence 
of  the  dislocation,  and  in  the  course  of  three  or  four  weeks  passive 
motion  should  be  commenced. 

IJxcision  of  the  "Wrist. — This  operation  consists  in  the  removal 
of  the  carpal  bones,  as  a  rule  ;  but  in  order  to  be  complete  the  lower 
extremities  of  the  radius  and  ulna  and  the  proximal  extremities  of  the 
metacarpal  bones  should  also  be  excised.  The  more  usual  indications 
are  chronic  disease  of  the  bones  or  their  joints. 

In  order  to  perform  this  excision  with  dexterity  the  anatomical 
features  of  the  bones  just  mentioned  must  be  understood.  The  carpal 
bones  are  united  by  a  capsular  ligament  strengthened  in  various  places, 
so  that  with  care  it  may  be  removed  as  a  single  layer  both  anteriorly 
and  posteriorly.  Posteriorly  and  laterally  the  bones  at  the  wrist  are 
practically  subcutaneous  ;  but  anteriorly  there  are  many  tendons,  nerves, 
and  vessels.  The  posterior  tendons  serving  as  guides  are  the  extensor 
longus  pollicis  and  the  extensor  tendons  of  the  index  finger,  the  radial 
artery  lying  to  the  outer  side  of  the  former  tendon  ;  while  between  the 
tendons  (Fig.  1 17)  is  a  space  crossed  by  the  radial  nerve,  and  offering 
a  safe  means  of  approach  to  the  radial  end  of  the  carpus.  In  this  space 
are  the  two  extensor  carpi  radialis  tendons.  On  the  radial  side  are  the 
extensor  tendons  of  the  thumb  and  its  metacarpus  ;  on  the  ulnar  side  are 
the  extensor  and  flexor  carpi  ulnaris  tendons.  The  exterior  tendons 
crossing  the  carpus  posteriorly  need  not  be  disturbed.  Anteriorly  are 
the  deep  and  superficial  flexors  of  the  fingers  and  long  flexor  of  the 
thumb,  together  with  the  median  and  ulnar  nerves  and  radial  and  ulnar 
arteries.  The  trapezium  is  important  surgically  from  the  fact  that  it 
supports  the  thumb  with  its  muscles,  is  in  close  proximity  to  the  radial 
artery,  and  that  a  groove  on  its  anterior  surface  lodges  the  long  flexor 
tendon  of  the  thumb.  Hence  this  bone  should  be  preserved,  if  possible. 
The  upper  bones  of  the  carpus  correspond  roughly  to  a  line,  convex 
upward,  which  connects  the  two  styloid  processes.  The  arteries  most 
liable  to  be  wounded  are  the  radial,  the  carpal  arches,  and  the  deep  arch. 

Bilateral  Incision. — This  operation  is  likely  to  be  long  and  tedious, 
but  should  be  made  as  subperiosteal  as  possible,  with  only  the  neces- 
sary sacrifice  of  tendons.     The  radial  incision  is  made  first.     It  should 


EXCISION  OF  BONES  AND  JOINTS. 


369 


commence  on  a  level  with  the  radial  styloid,  over  the  center  of  the 
posterior  surface  of  the  radius,  and  be  carried  downward  to  the  inner 
side  of  the  first  carpometacarpal  articulations  (Fig.  118,  a),  thence 
along  the  radial  side  of  the  second  metacarpal  for  half  its  distance, 
making  an  incision  about  4  inches  long.  It  lies  to  the  ulnar  side  of  the 
extensor  longus  pollicis  muscle,  should  be  carried  to  the  bone,  and  it 
will  probably  sever  the  two  extensor  carpi  radialis  tendons.  The  ulnar 
incision  is  on  the  inner  side  of  the  wrist,  commencing  about   2  inches 


Tendo  extens. 
digiti  quinti. 

Tendo  ext. 
carpi  //In. 


Tendo  ext.  carpi 
rad.  brev. 

Tendo  ext.  carpi 

rad.  long. 

V.  salvatella. 


Tendo  ext.  digit. 
comniun. 


—  X.  radialis. 

I '.  cephalica. 
A.  radialis. 
Tendo  abduct,  pollic.  long. 

Tendo  ex/ens.  poll.  brev. 
Tendo  extens.  poll.  long. 


FlG.  117. — Topography  of  the  dorsal  surface  of  the  hand:  Langenbeck's  resection-incision. 


above  the  ulnar  styloid  process,  and  is  carried  down  between  the  two 
ulnar  carpal  tendons  and  reaches  as  low  as  the  middle  of  the  fifth  meta- 
carpal bone  (Fig.  1 18,  I?). 

The  next  step  consists  in  removing  the  carpus  as  subperiosteally  as 
possible ;  it  may  include  the  carpus  as  a  whole,  or  each  bone  may  be 
removed  as  it  is  freed.  The  trapezium  is  separated  from  the  carpus  and 
preserved,  if  possible,  as  is  the  pisiform  also.  By  means  of  an  elevator 
the  periosteum  and  tendons  are  separated  from  the  carpal  bones  ante- 

24 


37° 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


riorly  and  posteriorly,  aided  by  alternately  flexing  and  extending  the 
hand  and  working  through  both  incisions.  On  the  radial  side  we  must 
guard  against  injury  to  the  radial  artery  and  the  long  flexor  tendon  of 
the  thumb,  if  the  trapezium  must  be  removed.  On  the  ulnar  side  there 
is  less  to  be  injured.  Thus  all  the  carpal  bones  are  to  be  bared  and 
removed  with  as  little  injury  to  tendons  as  is  possible.  Thus  far  the 
tendons  on  the  posterior  aspect  of  the  radius  and  ulna  should  not  have 
been  disturbed;  but  if  it  is  necessary  to  resect  a  portion  of  these  bones, 

the  general  layer  of  carpal  perios- 
teum is  to  be  elevated,  including 
the  extensor  tendons,  exposing  as 
much  bone  as  may  be  necessary. 
The  hand  may  be  everted  and  these 
extremities  removed  through  the  ul- 
nar incision,  according  to  the  exi- 
gencies of  the  case.  The  ends  of  the 
metacarpal  bones  are  to  be  exposed 
and  excised  if  necessary.  The  above 
incision  is  to  be  used  for  drainage  if 
such  is  demanded.  The  forearm  and 
hand  are  fixed  by  means  of  an  ante- 
rior splint,  and  the  fingers  left  free 
for  passive  motion.  Care  must  be 
taken  to  keep  the  hand  in  good 
position  until  the  tendons  and  bones 
become  readjusted  to  their  new  po- 
sition, and  consequently  the  splint 
must  be  worn  for  a  period  of  from 
two  to  six  months.  The  results 
from  this  operation  are  not  very 
satisfactory. 

Dorsoradial  Incision  {von  Lan- 
genbecli). — A  carpal  excision  may  be 
performed  through  a  single  straight 
incision  on  the  dorsum.  It  is  carried  along  the  ulnar  side  of  the 
second  metacarpal  bone  up  on  to  the  radius  (Fig.  118,  <■/),  and  is 
about  4  inches  long.  The  edges  of  the  wound  are  elevated  and 
retracted  laterally,  the  hand  strongly  flexed,  and  the  carpal  bones 
removed  one  by  one.  This  incision  is  less  convenient  than  the 
bilateral  method,  and  is  attended  with  the  sacrifice  of  more  tendons, 
as  well  as  adding  to  the  difficulties  of  an  already  complicated  oper- 
ation. The  length  of  time  necessaiy  to  perform  the  carpal  excisions 
renders  the  use  of  the  tourniquet  objectionable  on  .account  of  the  sub- 
sequent tendency  to  hemorrhage. 

Excision  of  the  Hip-joint. — This  is  usually  a  "  partial  "  excision, 
for  only  the  upper  extremity  of  the  femur  is  removed.  Anatomically 
we  have  to  deal  with  a  comparatively  simple  joint  which  is  deeply  sur- 
rounded by  large  muscles.  The  numerous  methods  of  excision  differ 
mainly  in  the  situation  of  the  primary  incision.  The  most  favorable 
location,  however,  is  the  outer  and  posterior  aspect. 

Von     Langenbeck's    Method    (Fig.    119,    a). — The    thigh    is    held 


Fig.  118. — Excision  of  the  wrist :  a,  radial 
incision;  bb,  ulnar  incision;  dd,  von  Lan- 
genbeck's incision. 


EXCISION   OF  BONES  AND  JOINTS. 


371 


flexed  at  an  angle  of  45  degrees  and  rotated  inward.  An  incision  about 
4J  inches  long  is  made  over  the  great  trochanter,  parallel  with  the  shaft 
of  the  femur,  two-thirds  of  which  will  be  above  the  trochanter,  and  con- 
sequently over  the  joint.  The  gluteal  muscles  will  be  divided  more  or 
less  in  the  direction  of  their  fibers,  and  thus  the  incision  is  carried  down 
to  the  bone  and  capsule.  The  latter  is  opened  in  the  line  of  the  orig- 
inal incision  as  well  as  by  a  second  transverse  incision  close  to  the 
acetabulum.  The  muscles  are  severed  from  their  trochanteric  attach- 
ment, the  ligamentum  teres  divided,  and  the  head  of  the  bone  turned 
out  into  the  wound.  Denudation  will  be  extended  as  may  be  neces- 
sary, and  the  exposed  bone  excised. 
The  acetabulum  should  be  curetted. 
It  is  safer  to  drain  the  wound. 

Ollier's  Method  (Fig.  1 19,  b). — This 
method  sacrifices  none  of  the  gluteal 
muscles  and  preserves  as  much  of  the 
capsule  as  is  possible.  The  incision  is 
a  curved  one,  beginning  about  3  inches 
below  the  crest  of  the  ilium,  midway 
between  the  anterior  and  posterior 
spines  of  the  ilium.  It  is  carried 
downward  and  backward  to  the  great 
trochanter,  severing  only  the  skin  and 
fascia,  thence  along  the  shaft  of  the 
femur,  through  all  the  muscles,  down 
to  the  bone.  Its  length  will  be  about 
5  inches.  The  lips  of  the  wound  are 
retracted,  and  the  gluteus  maximus 
will  be  seen  to  be  posterior  to  the  in- 
cision, and  the  fibers  of  the  gluteus 
medius  are  in  the  line  of  the  incision. 
These  are  to  be  separated,  and  not  di- 
vided; likewise  the  fibers  of  the  gluteus 
minimus.  The  smaller  muscles  about 
the  trochanter  and  neck  of  the  femur, 

such  as  the  pyriformis.gemelli,  and  obturators,  may  be  severed  or  retracted 
and  the  capsule  exposed.  The  next  step  consists  in  opening  the  upper 
surface  of  the  capsule  from  the  acetabulum  to  the  great  trochanter; 
then,  by  means  of  the  elevator,  the  capsule,  periosteum,  and  tendons  are 
removed  from  the  upper  extremity  of  the  femur.  The  head  of  the  bone 
is  to  be  dislocated  into  the  wound,  the  ligamentum  teres  severed  if  it  is 
not  already  destroyed,  and  the  head  firmly  grasped  by  forceps  and  then 
excised  as  extensively  as  may  be  necessary.  The  acetabulum  is  to  be 
curetted  as  occasion  demands.  The  wound  is  treated  according  to 
general  principles.  The  after-treatment  consists  in  fixation  and  moderate 
extension  of  the  leg. 

Anterior  Incision. — The  hip-joint  may  be  approached  by  an  ante- 
rior incision  about  4  inches  long,  extending  from  below  the  anterior 
superior  spine  of  the  ilium  toward  the  knee,  roughly  parallel  with  the 
inner  border  of  the  sartorius.  No  muscles  need  be  severed.  The  joint 
is  placed  nearer  the  surface,  but  the  acetabulum  is  not  so  well  exposed. 


Fig.  119. — Excision  of  the  hip:  a  a, 
von  Langenbeck's  method;  bb,  Ollier's 
method. 


372 


INTERNATIONAL    TEXTBOOK  OF  SURGERY. 


This     route    has    some    advantages,    but   the    lateral    incision    is    the 
favorite. 

Kxcision  of  the  Knee-joint. — The  success  of  this  operation 
depends  upon  obtaining-  ankylosis  in  the  extended  position,  and  the 
excision  should  be  "  complete."  Anatomically  the  knee  is  the  largest 
articulation  depending  upon  ligaments  for  its  strength. 

The  semilunar  incision  is  the  one  most  used  (Fig.  120).  The  knee 
is  held  partially  flexed,  and  the  knife  is  entered  at  the  posterior  and 
upper  part  of  one  condyle,  and  then  carried  down 
across  the  front  of  the  joint,  about  f  inch  below 
the  patella,  then  up  to  a  corresponding  point  on 
the  opposite  condyle.  This  incision  includes  only 
the  skin.  The  knee  is  then  to  be  flexed  a  little 
more,  the  ligamentum  patellar  is  divided,  and  then 
the  lateral  ligaments,  and  finally  the  capsule  is 
severed,  thus  opening  the  joint.  The  knee  is 
flexed  still  more,  and  by  rotating  the  leg  the  cru- 
cial ligaments  may  be  severed ;  but  the  strong 
posterior  ligament  is  to  be  preserved.  Elevate  the 
flap,  completely  flex  the  leg,  and  free  the  condyles 
according  to  the  conditions.  As  a  rule,  remove  as 
little  bone  as  is  necessary,  particularly  in  children. 
Remove  the  articular  surface  of  the  condyles  by 
sawing  from  before  backward  in  the  horizontal 
plane  of  the  articulation,  and  not  at  right  angles 
to  the  femoral  shaft,  otherwise  the  deformity  of 
knock-knee  or  bow-legs  may  be  produced. 

The  semilunar  cartilages  should  be  removed 
and  the  extremity  of  the  tibia  made  to  protrude 
from  the  wound ;  then,  by  sawing  from  before 
backward,  a  thin  lamina  of  bone  is  removed  in  the 
plane  of  the  joint,  injury  of  the  soft  parts  being 
guarded  against  by  retractors,  and  of  the  popliteal 
vessels  by  breaking  off  the  last  portion  of  this 
lamella.  The  patella  should  then  be  removed  according  to  the  judg- 
ment of  the  operator.  All  portions  of  the  capsule,  as  well  as  all  dis- 
eased spots,  should  be  thoroughly  removed.  The  ends  of  the  bones 
should  meet  in  perfect  approximation,  and  may  be  wired  or  not,  and 
the  wound  closed  with  or  without  drainage,  according  to  the  nature  of 
the  case. 

The  after-treatment  calls  for  absolute  rest  and  perfect  fixation  of  the 
limb.  If  the  wound  does  not  suppurate,  a  good  result  may  be  ex- 
pected ;  otherwise  the  case  will  be  very  tedious,  and  often  a  source  of 
much  pain.  The  results  following  this  excision  are  not  very  favorable, 
so  that  cases  of  faulty  ankylosis  are  best  corrected  by  osteotomy. 

Other  methods  of  excision  differ  principally  as  to  the  line  of  incision. 
Excision  of  the  Ankle-joint. — Excision  of  the  ankle-joint  was 
formerly  practised  quite  extensively,  but  nevertheless  the  results  were 
not  gratifying.  Severe  compound  fractures  about  the  ankle-joint  were 
commonly  treated  by  either  excision  or  amputation,  but  the  present 
surgical  methods  have  rendered  excision  almost  obsolete  for  this  class 


Fig.  120. — Excision  of 
the  knee  with  long  ante- 
rior flap  incision. 


EXCISION  OF  BONES  AND  JOINTS.  373 

of  cases.  Gunshot  wounds  no  longer  call  for  excision  as  a  routine. 
Tuberculosis  at  the  ankle-joint  is  commonly  overcome  by  other  meas- 
ures ;  or  if  the  joint  is  seriously  disorganized,  amputation  gives  a  more 
serviceable  leg.  Operation  is  furthermore  discouraging  on  account  of 
the  large  number  of  excisions  which  are  followed  by  amputation.  Cases' 
of  faulty  ankylosis  are  best  tested  by  osteotomy  rather  than  excision. 
The  after-treatment  is  tedious  and  uncertain,  and  frequently  demands 
considerable  mechanical  skill  in  the  application  of  splints  so  as  to  obtain 
fixation  and  at  the  same  time  permit  surgical  dressings  to  be  applied 
where    the  wound  has  suppurated. 

The  ankle-joint  is  a  hinge-joint,  well  supported  by  bone  and  held  by 
strong  ligaments.  The  operator  must  be  familiar  with  the  anatomy  of 
the  lower  extremity  of  the  tibia  and  fibula,  the  astragalus,  and  the  os 
calcis.  The  lateral  ligaments  are  strong,  but  the  anterior  and  posterior 
are  weak.  Many  tendons  surround  this  joint,  all  of  which  are  impor- 
tant in  strengthening  it,  and  should  not  be  cut  during  the  operation. 
Behind  the  outer  malleolus  are  the  two  peronei  tendons,  which  follow 
along  the  outer  subcutaneous  surface  of  the  os  calcis  ;  and  internally, 
behind  the  inner  malleolus,  are  in  general  the  plantar  flexor  muscles 
of  the  foot  and  toes.  Anterior  to  the  joint  are  the  dorsal  flexors,  but 
the  tendo  Achillis  is  at  a  safe  distance  posteriorly.  The  tibial  nerves 
and  vessels  need  not  be  injured. 

Lauenstein's  Operation  (Fig.  121). — The  advantage  of  this  method 
is  that  the  joint  can  be  well  exposed  by  a  single  incision.     This  incision 


Fig.  121. — Excision  of  the  ankle. 

begins  near  the  shaft  of  the  fibula,  about  2  inches  above  the  malleolus, 
and  is  carried  down  just  below  the  extremity  of  the  bone,  and  then 
curves  forward  toward  the  dorsum  of  the  foot,  terminating  in  the  vicinity 
of  the  astragaloscaphoid  articulation.  Over  the  fibula  the  incision  should 
be  carried  to  the  bone,  then  with  the  elevator  the  periosteum  is  reflected 
backward,  carrying  with  it  the  two  peronei  tendons  undisturbed  in  their 
sheath.  The  periosteum  is  likewise  reflected  from  in  front  of  the  fibula. 
The  external  lateral  ligament  is  to  be  cut,  and  then  the  malleolus  entirely 
exposed,  and  at  this  point  the  lower  inch  or  more  of  this  bone  removed 
by  saw  or  forceps. 

Continuing  with  the  elevator,  the  anterior  and  then  the  posterior  sur- 


374 


INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 


faces  of  the  lower  extremity  of  the  tibia  are  to  be  exposed,  during  which 
process  the  tendons  and  other  structures  are  to  be  retracted  respectively 
forward  or  backward.  It  will  now  be  possible  completely  to  invert  the 
foot  at  this  articulation,  thereby  exposing  the  joint-surfaces  of  the  tibia, 
fibula,  and  astragalus  (Fig.  122).  These  surfaces  are  to  be  treated 
according  to  the  principles  governing  cases  of  resection,  as  considered 
above.  It  is  advisable  to  remove  as  little  tissue  as  is  consistent  with 
expediency.     The  foot  is  then  to  be  replaced  and  the  wound  closed. 


Patella. 


Astragalus. 

Tendon  of  pero- 
neus  longus. 


M.  peroneus  tertius. 


Irticular  surface 
oj  tibia. 


Malleolus  externus. 


Capsule. 


Fig.   122. — Resection  of  the  ankle. 


Bilateral  Incision. — The  outer  incision  is  carried  down  over  the 
fibula  as  above ;  but  at  the  tip  of  the  bone  it  is  usually  carried  only  a 
short  distance  either  forward  or  backward.  The  internal  incision  is  a 
short  one  over  the  lower  portion  of  the  internal  surface  of  the  tibia 
and  internal  malleolus.  Through  this  incision  the  periosteum  and  liga- 
ments are  removed  from  this  bone,  and  through  the  external  incision 
the  parts  are  treated  as  in  the  unilateral  operation.  When  the  diseased 
tissue  has  been  removed,  the  wounds  are  to  be  closed. 

After-treatment. — Favorable  cases  can  be  closed  without  drainage, 
and  the  leg  fixed  with  plaster  of  Paris  ;  but  such  results  are  not  the 
rule.  The  cause  of  operation  in  most  instances  is  such  that  suppuration 
is  unavoidable,  and  this  complication  renders  the  after-treatment  labo- 
rious and  very  uncertain  as  to  its  outcome.  The  problem  is  to  main- 
tain fixation  and  rest  with  the  foot  in  good  position,  and  yet  allow  access 
to  the  wound  for  dressings.     Various  contrivances  may  be  used,  such 


OSTEOTOMY.  Ul 

as  fenestrated  plaster  casts,  posterior  wire  splints,  or  even  a  special  appa- 
ratus for  particular  cases.  The  discouraging  feature  in  most  of  these 
suppurative  cases  is  that,  after  months  or  years  of  treatment,  ampu- 
tation must  be  resorted  to  in  order  to  obtain  a  useful  limb. 

Arthrectomy  or  Brasion  of  a  Joint. — The  close  relation 
between  arthrectomy  and  excision  is  such  that  this  method  of  treating 
diseased  joints  should  be  considered  briefly  in  this  connection.  By  the 
term  arthrectomy  or  erasion  of  a  joint  we  mean  the  thorough  exposure 
of  the  joint  by  one  method  or  another,  together  with  the  thorough 
removal  of  the  diseased  tissue  alone.  Hence  this  method  cannot  be 
applied  to  extensively  diseased  bones  and  joints,  but  only  to  cases 
where  the  destruction  is  still  superficial.  It  is  practically  a  curetting  of 
the  joint,  and  is  to  be  used  particularly  in  the  early  stages  of  articular 
disease.  The  operation  must  always  be  performed  with  care,  and  it 
requires  experience  to  determine  when  all  the  pathological  tissue  has 
been  removed,  particularly  in  the  cancellated  bone.  Arthrectomy  offers 
the  advantage  of  a  little  or  no  shortening  of  the  limb,  as  well  as  but 
slight  tendency  to  deformity.  For  the  reason  that  it  is  a  measure  suit- 
able for  early  cases,  the  results  are  more  favorable  than  those  following 
excision. 

As  a  rule,  each  joint  must  be  exposed  by  the  methods  used  in  excis- 
ion of  the  same  joint ;  but  the  loss  of  tissue  and  the  mutilation  neces- 
sary in  the  two  operations  are  very  different,  hence  the  better  immediate 
prognosis  in  cases  of  arthrectomy.  In  point  of  fact,  most  cases  of 
excision  are  modified  by  the  operation  of  erasion.  For  the  reason  that 
the  exact  condition  of  a  diseased  process  in  a  joint  can  often  be  deter- 
mined only  after  it  has  been  opened  and  explored,  it  is  well  to  begin  the 
operation  with  the  idea  of  performing  an  arthrectomy.  Extreme  cases 
of  joint-disease  will  probably  be  more  benefited  from  all  points  of  view 
if  an  amputation  is  performed  at  the  outset,  thus  avoiding  a  long  period 
of  suppuration  with  possible  serious  consequences. 

OSTEOTOMY. 

Osteotomy  is  the  term  used  to  describe  any  division  of  a  bone  in 
situ ;  but  practically  it  means  the  division  of  bone  for  the  relief  of 
deformity.  This  limits  the  operation  to  the  correction  of  deformity  fol- 
lowing fracture,  of  the  distortion  of  rickets,  and  of  certain  ankyloses  fol- 
lowing joint-disease. 

Osteotomy  may  be  performed  either  with  the  saw  or  with  the  osteotome. 
The  latter  is  to-day  the  instrument  of  choice  for  nearly  all  operations  of 
this  class.  It  can  be  handled  with  equal  or  greater  precision,  though  it 
requires  rather  more  skill  than  the  saw.  It  involves  less  risk  of  injury 
to  the  soft  parts,  and  does  not  fill  the  wound  with  bone-dust  and  chips, 
which  may  be  innocuous,  but  may  act  as  foreign  bodies  and  become  the 
starting-point  of  an  infection. 

The  osteotome  in  common  use  is  that  of  Macewen — substantially  a 
simple  chisel,  but  with  an  edge  not  bevelled,  but  ground  evenly  from 
both  surfaces.  The  sides  are  straight ;  the  cutting-edge  is  straight  and 
of  a  width  of  f  to  f  inch,  usually  about  \  inch.  It  is  well  to  have 
osteotomes  of  different  thicknesses,  so  that  the  thinner  may  be  used  to 


376  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

complete  the  cutting  with  less  risk  of  becoming  wedged  or  of  splintering 
the  bone.  Markings  on  the  blade  at  |-inch  intervals  make  it  easy  to 
judge  of  the  depth  reached  by  the  cut.  The  mallet  used  is  preferably 
a  moderately  light  carpenters'  wooden  mallet,  rather  than  the  steel  or 
lead  ones  sometimes  advocated. 

For  the  performance  of  the  operation,  the  limb,  after  careful  anti- 
septic preparation,  is  placed  firmly  on  a  sand-bag,  and  an  incision  is 
made  at  the  desired  point. 

There  is  rarely  need  of  the  free  incision  often  advised ;  the  small 
space  needed  for  inserting  the  osteotome  is  gained  by  a  short  scalpel-cut 
reaching  to  the  bone,  though  it  is  often  practicable  to  drive  the  chisel 
itself  through  the  skin  and  down  to  the  bone.  The  bone  once  reached, 
the  blade  is  turned  to  the  desired  position,  avoiding  damage  to  the 
periosteum,  and  the  bone  is  cut  with  repeated  hammer-strokes,  the 
chisel  being  firmly  held  in  the  left  hand,  the  outer  side  of  which  should 
rest  on  the  skin,  to  avoid  slipping.  After  each  cut  the  chisel  should  be 
slightly  lifted  or  rocked  by  the  left  hand  to  avoid  wedging  ;  it  should 
never  be  removed  from  the  bone,  as  the  cut  made  may  easily  be  lost. 
The  osteotome  is  to  be  directed  now  forward,  now  backward,  as  needed  to 
ensure  cutting  the  full  width  of  the  bone,  until  about  two-thirds  or  three- 
fourths  of  the  thickness  of  the  bone  has  been  traversed,  when  an  attempt 
is  made  to  correct  the  deformity.  The  mechanism  is,  in  children,  a 
bending  of  the  uncut  portion  with  gaping  or  impaction,  as  the  case  may 
be,  of  the  opposite  side.     In  adults  the  bone  more  usually  breaks  across. 

Cuneiform  osteotomy  is  required  only  where  there  is  much  deformity. 
In  such  cases  the  wedge  removed  will  correspond  to  the  deformity  ; 
but  it  is  always  less  in  width  than  would  theoretically  be  needed  to 
ensure  a  full  correction.  Here  again  correction  may  be  obtained  with- 
out cutting  through  the  entire  bone.  The  operation  requires,  of  course, 
a  larger  incision  than  linear  osteotomy,  in  order  to  allow  for  cutting  as 
well  as  the  subsequent  removal  of  the  wedge.  It  is  a  severe  as  well  as 
a  somewhat  more  difficult  operation.  In  certain  cases,  as  in  bony  anky- 
losis of  the  knee  in  the  flexed  position,  it  is  essential  to  remove  bone  ; 
but  unless  the  total  thickness  of  bone  is  very  considerable,  a  very  accu- 
rate adjustment  of  the  cut  surfaces  is  not  essential  to  the  result. 

Osteotomy  for  Faulty  Ankylosis  of  the  Hip-joint. — This 
operation  is  carried  out  in  the  treatment  of  certain  cases  of  ankylosis  in 
which  the  hip  is  fixed  or  its  motion  limited  in  such  a  way  that  the 
normal  erect  attitude  is  impossible.  This  includes  not  only  the  cases 
of  actual  ankylosis  of  the  joints,  but  cases  in  which  there  is  some  little 
motion  preserved  at  the  hip,  and  in  which  the  position  of  the  limb  is 
such  as  to  preclude  normal  use.  Most  usually  these  operations  are 
done  to  better  the  condition  of  imperfectly  cured  tubercular  disease. 
The  result  aimed  at  is  in  no  sense  a  restoration  of  joint-function,  but  a 
fresh  ankylosis  in  improved  position. 

The  osteotomy  is  performed  either  through  the  femoral  neck  or 
across  the  shaft  below  the  trochanter. 

I.  Through  the  Neck  of  the  Femur  {Adams's  Operation)  (Fig.  123, 
A). — Adams  writes :  "  The  narrow-bladed  knife  is  pushed  in  till  it 
reaches  the  neck  of  the  femur,  at  a  right  angle  across  the  front  of  which 
it  is  then  carried.     The  knife  is  then  gently  moved  to  cut  a  space  for 


OSTEOTOMY. 


377 


the  easy  insertion  of  the  saw,  which,  traversing  the  course  of  the  knife, 
reaches  the  front  of  the  neck  of  the  femur,  and  gradually  cuts  it  com- 
pletely through.  The  surgeon  cuts  until  he  feels 
that  the  saw  is  free  of  the  bone,  and  moving  in 
the  soft  tissues  only  behind  the  bone."  The 
point  for  beginning  the  incision  is  about  a  finger's 
breadth  above  the  great  trochanter.  The  saw 
used  for  this  operation  is  the  special  one  shown 
in  Fig.  124. 

The  operation  may  be  performed  equally  well 
with  the  osteotome  ;  the  incision  is  made  in  the 
same  way,  the  osteotome  introduced  and  turned 
to  a  right  angle  with  the  femoral  neck,  which  is 
then  simply  divided  across. 

The  operation  has  certain  drawbacks  :  first,  it 
is  inapplicable  in  the  frequent  cases  in  which  the 
femoral  neck  is  shortened  or  absorbed  as  a  re- 
sult of  disease ;  secondly,  satisfactory  reposition 
is  not  always  easy  after  the  bone  is  completely 
divided. 

II.  Through  the  Shaft  of  the  Femur  below  the  Trochanter 
{Ganfs  Operation)  (Fig.  123,  B). — The  incision  for  this  operation  is  i| 
inches  below  the  trochanter  major  ;  it  may  well  be  made  with  the  chisel, 
which  is  driven  through  the  skin  directly  inward  till  it  reaches  the  bone, 


FIG.  123. — Osteotomy  for 
ankylosis  of  hip:  A,  intra- 
capsular (Adams's)  opera- 
tion ;  B,  extracapsular 
(Gant's)  operation. 


^k^^a^si^a^i^»lf!^!^ 


Fig.  124. — Adams's  saw  for  subcutaneous  division  of  the  neck  of  the  femur. 


and  then  turned  till  the  blade  is  at  right  angles  to  the  line  of  the  femoral 
shaft.  The  bone  is  cut  across  just  below  the  lesser  trochanter.  It  is 
well  not  to  divide  the  bone  entirely,  but  to  leave  a  small  portion  to  be 
broken  when  the  deformity  is  corrected,  thus  ensuring  better  apposition 
of  the  fragments.  The  limb  is  put  up  with  proper  correction  of  previous 
deformity  ;  and  if  there  is  some  shortening,  this  may  be  practically 
equalized  by  slight  abduction  of  the  leg  in  the  fixation-apparatus.  It 
may  sometimes  be  necessary,  in  order  to  correct  fully,  to  divide  con- 
tracted bands  of  fascia  through  an  incision  anterior  to  the  joint.  Con- 
finement to  bed  for  about  six  weeks  is  necessary. 

The  results  are  excellent,  and,  though  it  is  theoretically  less  nearly 
correct,  this  operation  is  preferable  to  that  of  Adams  in  a  great  majority 
of  cases.  The  longer  incision  and  the  excision  of  a  wedge,  advocated  by 
Volkmann,  seem  to  be  unnecessary  in  practice. 

An  operation  is  described  (Volkmann)  by  which  correction  of  the 
deformity  is  attained,  and  an  attempt  made  to  secure  a  serviceable  false 
joint.  The  bone  is  cut  across  below  the  trochanters,  and  the  upper  end 
of  the  shaft  shortened  to  give  room,  and  rounded  off  to  fit  into  a  cup 
scooped  out  of  the  trochanter.  Cases  are  reported  sufficiently  success- 
ful to  show  the  possibility  of  such  a  result,  but  the  method  is  as  yet 
insufficientlv  tried  to  be  regarded  as  established. 


378 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


Osteotomy  for  Genu  Valgum. — This  operation  is  performed  in 
all  adult  cases  <>f  knock-knee  requiring  treatment,  and  in  children  in 
most  cases  in  which  the  deformity  that  follows  active  rickets  has  taken 
place.  It  has  been  done  as  early  as  the  third  year;  but  permanently  good 
results  may  be  more  confidently  expected  if  four  years  be  taken  as  the 
limit.  Various  open  operations  for  the  rectification  of  knock-knee  have 
been  performed,  to  say  nothing  of  the  methods  of  forcible  correction, 
osteoclasis,  etc. ;  but  the  only  operation  accepted  as  a  routine  measure 
to-day  is  the  supracondyloid  osteotomy.  The  deformity  in  the  usual 
form  of  knock-knee  depends  essentially  upon  a  relative  overgrowth  of 
the  inner  condyle  of  the  femur.  This  cannot  be  perfectly  corrected ; 
but  by  changing  the  direction  of  the  bone  just  above  the  growing 
epiphysis,  a  straight  general  line  is  given  to  the  leg,  and  the  deformity 
resulting  from  the  operation  is  trifling  (Fig.  125). 

Macewen's  Supracondyloid  Osteotomy  of  the  Femur. — For  this 
operation    the   flexed   knee  is  laid  on    its   outer    side   on  a  sand-bag, 

and  a  longitudinal  incision  is  made  at  a 
point  \  to  f  inch  above  the  adductor  tu- 
bercle, anterior  to  the  insertion  of  the  ad- 
ductor magnus.  Fither  a  scalpel  is  used, 
or  the  osteotome  is  driven  directly  into  the 
bone,  and  then  turned  into  such  position 
that  it  will  divide  the  bone  in  a  direction 
outward  and  sufficiently  upward  to  avoid 
the  epiphyseal  cartilage  (Fig.  125).  Care 
must  be  taken  to  move  the  chisel  suf- 
ficiently to  prevent  its  becoming  wedged, 
and  to  direct  it  forward  and  backward 
enough  to  ensure  cutting  the  anterior  and 
posterior  walls  of  the  bone  completely 
through.  When  two-thirds  or  three- 
fourths  of  the  bone  has  been  divided,  an 
attempt  should  be  made  to  correct  the  de- 
formity. If  the  division  has  been  properly 
carried  out,  the  outer  cortical  layer  of  the 
bone  bends  or  breaks,  and  there  is  impac- 
tion on  the  inner  side,  giving  a  complete 
correction  with  fixation  of  the  fragments. 
Neither  drainage  nor  sutures  are  neces- 
sary. A  plaster-of-Paris  bandage  is  worn  for  about  four  weeks,  and  the 
child  allowed  to  stand  on  the  leg  at  about  six  weeks,  or  even  less,  after 
operation.  The  functional  as  well  as  the  esthetic  results  are  excellent ; 
the  mortality  is  trifling  (less  than  \  per  cent.). 

Accidental  wounding  of  the  anastomotica  magna  and  injur}'  to  the 
peroneal  nerve  should  be  mentioned  as  rare  complications  that  have 
occurred  in  connection  with  this  operation. 

Osteotomy  of  the  Shaft  of  the   Femur   from    the  Outer  Side. 

The  thigh  is  adducted  and  inverted,  and  a  short  transverse  incision,  2 
inches  above  the  external  condyle,  is  carried  through  the  iliotibial  band 
to  the  bone.  The  chisel  is  then  inserted  and  the  shaft  cut  through 
transversely  till  the  outer  surface  is  nearly  reached  ;  the  correction  is 


Fig.  125. — Section  of  femur  in 
knock-knee,  showing  line  of  sec- 
tion in   Macewen's  operation. 


OSTEOTOMY.  379 

then  carried  out  as  before.  In  this  operation  there  is  gaping  rather 
than  impaction  of  the  cut  surfaces. 

This  operation,  though  unobjectionable,  has  largely  been  abandoned 
for  that  of"  MacEwen. 

Osteotomy  for  Faulty  Ankylosis  of  the  Knee-joint. — In 
cases  of  ankylosis  in  which  forcible  straightening  is  contra-indicated  or 
impossible,  a  linear  osteotomy  above  the  condyles  may  be  done,  differ- 
ing from  the  typical  MacEwen  operation  only  in  that  the  anterior  wall 
is  completely  divided,  and  the  posterior  instead  of  the  external  wall 
left  uncut,  to  be  broken  across  by  the  manipulations  for  correction. 
It  may  often  be  wise  not  to  attempt  full  correction  immediately,  but  to 
secure  a  partial  correction,  and  reach  the  final  result  by  straightening 
the  knee  a  little  more  at  each  dressing.  An  advantage  of  this  opera- 
tion is  that  it  makes  it  possible  to  preserve  and  use  such  motion  as 
may  have  been  present  before  correction. 

The  operation  is  an  excellent  means  of  correcting  faulty  ankyloses 
up  to  about  45  degrees  of  flexion  ;  more  extensive  flexion  with  anky- 
losis is  usually  better  treated  by  a  wedge-shaped  excision  of  the  joint ; 
or  linear  osteotomy  of  the  tibia  just  below  the  knee  may  be  added  to 
the  osteotomy  of  the  femur. 

Osteotomy  of  the  Tibia. — Three  operations  are  done  on  the 
tibia — linear  osteotomyjust  below  the  tuberosities,  performed  in  knock- 
knee  or  in  ankylosis  of  the  knee;  linear  osteotomy  of  the  shaft  for  the 
correction  of  bowlegs  or  deformed  fractures;  and  cuneiform  osteotomy 
for  the  same  purpose. 

Osteotomy  of  the  Tibia  below  the  Tuberosities.— A  transverse 
incision  is  made  just  below  the  tuberosities  of  the  tibia,  carried 
from  the  spine  backward  across  the  inner  side,  and  the  bone  divided 
transversely,  the  chisel  being  driven  from  within  outward  as  the  poste- 
rior portion  of  the  bone  is  reached,  and  great  care  being  taken  to  avoid 
injury  of  the  structures  at  the  outer  side. 

By  another  method,  an  anterior  longitudinal  incision  is  used,  and 
bent  retractors  are  introduced  behind  the  bone,  between  it  and  the  soft 
parts,  thus  protecting  the  popliteal  space  from  the  final  blows  of  the 
chisel. 

The  fibula  is  not  always  divided  in  this  operation,  but  the  danger 
of  injuring  the  peroneal  nerve  is  said  to  be  lessened  when  this  bone  is 
carefully  chiselled  across.  For  this  purpose  an  incision,  a  little  below 
the  fibular  head,  is  carried  direct  to  the  bone,  which  is  divided  with  the 
osteotome. 

According  to  Kocher,  the  liability  to  damage  of  this  nerve  during 
the  reduction  is  less  if  a  wedge-shaped  osteotomy  of  the  tibia  is  resorted 
to,  as  less  force  need  be  used. 

Linear  Osteotomy  of  the  Tibia. — This  is  the  operation  of  choice 
for  such  bowlegs  as  cannot  be  dealt  with  by  osteoclasis — especially 
for  the  "  anterior  bowlegs,"  in  which  the  bend  is  usually  a  sharp 
and  well-localized  one,  and  for  bends  very  near  the  epiphyses. 

A  rather  broad  osteotome  is  introduced  through  a  knife-cut  at  the 
point  of  maximum  curve ;  the  bone  is  partly  divided  transversely,  and 
the  correction  completed  by  the  fracture.  When  there  is  marked 
deformity,  the  posterior  wall  of  the  tibia  may  be  chiselled  first ;  then 


380  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

there  will  be  a  gap  posteriorly  instead  of  an  anterior  impaction.  In 
this  way  something  may  be  saved  in  the  matter  of  shortening.  Fre- 
quently a  tenotomy  of  the  tendo  Achillis  is  necessary  to  a  full  and 
easy  correction.  Chiselling  of  the  fibula  is  rarely  required  ;  the  bone 
gives  way  in  a  green-stick  fracture  as  the  tibia  is  corrected. 

The  operation  for  deformity  after  fracture,  not  infrequently  per- 
formed in  this  situation,  is  essentially  the  same,  save  that  the  fibula  in 
these  cases  should  usually  be  divided  through  an  appropriate  external 
incision. 

Trendelenburg's  supramalleolar  osteotomy  for  the  relief  of  flat-foot 
is  practically  the  same  operation. 

Cuneiform  Osteotomy  of  the  Tibia. — This  operation  is  rarely 
required,  and  is  performed  only  in  cases  in  which  the  deformity  is 
extreme,  and  consists  of  a  single  bend  in  the  bone.  An  incision  is 
made  over  the  convexity  of  the  bend,  and  a  wedge,  corresponding  to 
the  degree  and  direction  of  the  deviation  to  be  corrected,  is  chiselled 
out  and  removed.  The  base  of  the  wedge  is  usually  directed  ante- 
riorly. 

Osteotomy  for  Hallux  Valgus. — This  operation,  according  to 
Barker  and  Reverdin,  is  an  improvement  on  the  resection  of  the  joints 
which  was  previously  practised  in  these  cases.  An  incision  is  made  to 
the  inner  side  of  the  great-toe  joint,  long  enough  to  admit  the  osteo- 
tome about  \  inch  behind  the  joint-line.  The  bone  is  cut  nearly 
through,  then  fractured  into  the  desired  position  and  held  by  suitable 
apparatus.  In  very  severe  cases  it  may  be  necessary  to  resect  a  wedge 
of  bone  at  this  joint  to  secure  the  desired  connection.  The  result  of 
either  operation  is  good  in  all  but  the  very  worst  cases. 

In  this  class  the  operation  described  by  Weir  seems  more  complete, 
more  rational,  and  more  likely  to  give  the  best  results.  He  advocates 
cutting  the  joint-capsule  on  the  outer  side,  with  partial  resection  of  the 
head  of  the  metatarsal,  especially  the  hypertrophied  inner  and  anterior 
surface.  The  cartilage  of  the  phalanx  is  not  cut,  so  that  motion  is 
preserved.  The  sesamoids  are  removed  (their  absence  seems  not  to 
interfere  with  perfectly  efficient  flexion).  In  some  cases  preservation 
of  the  corrected  position  of  the  toe  has  been  aided  by  transplanting 
the  extensor  proprius  hallucis  tendon  to  the  inner  side  of  the  first 
phalanx. 

Osteotomy  for  Inveterate  Club-foot. — The  removal  of  a  wedge 
of  bone  with  the  apex  at  the  inner  side  of  the  foot  is  not  infrequently 
performed  in  cases  of  inveterate  club-foot  with  marked  deformity  which 
have  resisted  all  other  means  of  treatment. 

In  this  operation  a  wedge  is  removed  irrespective  of  bony  boundaries 
— a  wedge  composed  externally  mainly  of  the  cuboid  and  the  anterior 
end  of  the  calcaneus,  internally  cutting  through  or  including  the  sca- 
phoid. It  may,  however,  include  parts  of  all  the  tarsal  bones  (Fig.  126). 
Various  incisions  are  used.  An  oval  may  be  excised  externally,  in- 
cluding the  callus  and  the  bursa  present  in  these  cases  over  the  cuboid, 
with  a  corresponding  simple  vertical  incision  at  the  inner  side.  A 
T-shaped  cut  with  the  vertical  arm  running  over  toward  the  scaphoid 
may  be  used,  or  a  simple  transverse  incision  from  the  scaphoid  across 
the  dorsum  of  the  foot  to  the  outer  side.     In  any  case,  the  next  step  is 


OSTEOTOMY. 


;Si 


Fk;.  126. — Incisions  for  cu- 
neiform resection  of  the  bones 
in  club-foot:  ab,  simple  trans- 
verse incision  ;  a  bee,  T-shaped 
incision  ;  d,  oval  incision. 


the  pushing  of  the  extensor  tendons  up  and  inward,  the  peroneous 
longus  tendon  down  and  back.  The  bones  are  carefully  cleared  with 
the  periosteal  elevator;  then,  the  wound-edges  being  held  separated 
with  retractors,  a  wedge  is  removed  with  saw  or  chisel,  so  that  the  foot 
can  be  brought  into  a  fully  corrected  position.  This  wedge  should  be 
so  cut  as  to  be  brought  out  in  one  piece. 

Suturing   the   bones  in  apposition  is  advocated,  but   is   not  really 
essential.     Any  hemorrhage  is  to  be  controlled,  the  external  wound 
sutured   with    or    without   drainage,   and   the 
foot  then  fixed  in  plaster-of-Paris  in  full}7  cor- 
rected position. 

Union  should  be  firm  in  about  six  weeks; 
but  the  operation  should  be  followed  by  mas- 
sage and  suitable  exercises,  and  a  retentive 
apparatus  worn  for  a  considerable  time  after 
this,  if  the  best  results  are  to  be  obtained. 
The  results  of  this  operation  are  good  ;  but 
the  operation  is  a  severe  one,  and  usually  re- 
sults can  be  obtained  without  so  much  sacri- 
fice of  bone,  which  necessarily  results  in  con- 
siderable shortening  of  the  foot. 

A  more  rational  form  of  osteotomy  for 
club-foot  consists  in  cutting  a  wedge  from 
the  anterior  end  of  the  os  calcis,  while  a  sec- 
tion of  the  neck  of  the  astragalus,  performed 

from  the  inner  side,  practically  continues  the  line  of  the  wedge  incision, 
and  makes  full  connection  possible  with  substantially  no  loss  of  bone. 
If  this  operation  be  done,  where  needed,  as  the  last  stage  of  Phelps's 
operation — division  of  all  resistant  structures  by  open  incision — it  gives 
a  means  of  correction  in  all  cases  save  those  with  extreme  deformity 
in  adults,  where  the  formal  wedge-shaped  osteotomy  described  above 
may  still   be   necessary. 

Operation  for  Talipes  Bcruinus. — This  operation,  originated,  as 
was  that  for  equinovarus,  by  Davy,  is  substantially  the  operation  just 
described,  save  that  the  base  of  the  wedge  removed  is  directed  upward 
instead  of  outward. 

For  the  skin-incision,  either  wedge-shaped  pieces  of  skin  may  be 
cut  out  on  either  side  corresponding  to  the  bone-wedge  to  be  removed, 
or  T-shaped  incisions  may  be  used.  Like  the  wedge-osteotomy  for 
varus,  this  operation  entirely  disregards  bony  landmarks.  It  consists 
simply  of  stripping  up  and  protecting  the  soft  parts  while  such  a  bony 
wedge  is  sawed,  or  better  chiselled  out,  as  will  enable  the  foot  to  be 
brought  to  the  corrected  position  and  held,  with  or  without  suturing 
the  bones  in  place.  The  after-treatment  is  the  same  as  that  for  the 
varus  operation — fixation  in  a  corrected  position  till  bony  union  is 
completed;  then  massage  and  exercises  till  the  foot  is  ready  for  use. 

Operation  for  Flat-foot. — In  cases  of  extreme  flat-foot,  a  wedge- 
shaped  osteotomy  may  be  performed  according  to  the  method  of 
Golding  Bird.  The  wedge  removed  consists  of  the  scaphoid,  or  of  the 
scaphoid  and  part  of  the  astragalus.  For  the  best  correction,  the  cut 
should  extend  across  the  full  width  of  the  tarsus  to  its  outer  border. 


^2  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

In  this  way  adduction  of  the  front  part  of  the  foot  as  a  whole  is  pos- 
sible, and  moderately  accurate  apposition  of  the  cut  surfaces  with 
restoration   of  the   arch. 

Cystorts  operation  is  a  wedge-osteotomy  of  parts  of  the  scaphoid 
and  of  the  astragalus.  The  astragalus  and  scaphoid  are  pegged  in 
their  relative  positions  after  correction  of  the  foot,  the  object  aimed  at 
being  ankylosis  of  these  bones. 

Schwartz  describes  a  wedge-resection  which  is  substantially  that  of 
Golding  Bird.  The  incision  is  made  from  .',  inch  in  front  of  the  internal 
malleolus  to  the  first  cuneiform  bone.  The  soft  parts  are  stripped  up, 
and  a  wedge-cut,  irrespective  of  the  joints,  but  including  usually  the 
scaphoid  and  a  part  of  the  astragalus,  is  removed.  The  foot  is  then 
fixed  in  corrected  position,  the  internal  cuneiform  and  the  neck  of  the 
astragalus  coming  in  contact. 

In  relation  to  these  operations,  it  is  to  be  remembered  that  they  all 
necessarily  sacrifice  something  of  the  "length"  and  of  the  elasticity  of 
the  foot,  and  can  in  no  proper  sense  cure  the  deformity ;  while  it  is  pos- 
sible by  mobilization,  forced  correction,  mechanical  support,  and  exer- 
cises actually  to  cure  many  cases  and  to  give  great  relief  to  nearly  all. 

Golding  Bird  would  limit  operation  to  such  cases  as  have  persistent 
pain  irrespective  of  support  and  correction,  due,  he  thinks,  to  crowding 
together  of  the  structures  at  the  outer  side  of  the  foot.  It  is  certain 
that  the  class  of  cases  of  flat-foot  to  be  operated  upon  is  confined  to 
those  in  whom  nothing  is  to  be  gained  by  other  treatment,  and  in  whom 
the  relief  of  pain  and  the  fair  functional  results  attainable  by  the  oper- 
ation distinctly  offset  its  disadvantages.  This  class  of  cases  is  decidedly 
a  small  one. 

Operative  Treatment  of  Ununited  Fracture. — In  the  treat- 
ment of  ununited  fracture  of  the  long  bones — femur,  tibia,  and  the 
bones  of  the  upper  and  lower  arm — many  authors  have  recommended 
various  measures  to  promote  union  without  actual  resection.  These 
would  seem  of  little  or  no  value  in  well-established  cases  of  non-union. 
There  are,  of  course,  the  frequent  cases  of  delayed  union,  not  definitely 
separated  as  a  class,  in  which  union  finally  occurs  apparently  irre- 
spective of  treatment.  In  these  cases  no  resection  is  needed;  and  now 
that  we  have  the  assistance  of  the  .f-rays,  it  will  probably  be  possible 
to  separate  the  cases  in  which  resection  is  advisable,  the  established 
pseudarthroses  in  which  no  further  repair  is  to  be  expected.  These 
are  of  two  classes — those  in  which  a  new  joint  has  been  formed,  often 
a  rough  ball-and-socket  joint;  and  those  in  which  there  has  been  not 
a  new  growth,  but  rather  an  actual  absorption  of  the  bone-ends. 

Many  methods  of  resection  of  bone-ends  for  these  cases  have  been 
described,  usually  differing  only  in  minor  details  of  no  very  definite 
value.  The  simplest  method,  and  probably  the  most  efficient,  consists 
of  a  transverse  resection  of  the  tips  of  the  fragments,  together  with 
such  external  apparatus  as  is  necessary  to  ensure  close  coaptation  of 
the  cut  surface. 

Operation  by  Resection  of  the  Ends  of  the  Bones. — This  oper- 
ation is  usually  simple,  the  points  of  most  importance  being  the  strict- 
est antisepsis,  free  incision,  and  accurate  coaptation.  The  incision  is 
so  placed  as  to  reach  the  bone  by  the  shortest  route,  and  must  be  suf- 


OSTEOTOMY.  $8$ 

ficiently  long  to  allow  the  free  end  of  each  fragment  to  be  brought  out 
of  the  wound.  The  bones  should  be  well  denuded  of  the  tough  cica- 
trix which  surrounds  them,  and  the  denuded  ends  brought  out  within 
reach  of  the  chisel  or  saw.  This  is  important,  not  only  in  order  to 
avoid  injury  of  the  soft  parts,  but  to  make  the  section  of  the  bones 
more  accurate.  Either  chisel  or  saw  may  be  used,  preferably  the  latter, 
and  so  much  of  the  ends  cut  away  as  may  be  necessary  to  give  a  fresh 
surface  of  spongy  bone.  Great  care  should  be  used  in  making  the 
section  accurately  transverse,  as  accurate  coaptation  of  the  fresh  sur- 
face and  easy  retention   of  position  depend  largely  on  this  point. 

The  after-treatment  is  carried  out  exactly  on  the  lines  of  an  ordinary 
compound  fracture,  except  that  extra  care  is  to  be  taken  in  the  matter 
of  immobilization. 

Operation  by  Wiring  the  Fragments. — In  this  operation  the  details 
of  preparation — incision,  the  denuding  of  the  bone-ends,  and  the  removal 
of  a  portion  of  the  ends — are  carried  out  in  precisely  the  same  way  as 
for  simple  resection.  Then  holes  are  drilled  through  the  cortical  layer, 
J  to  J  inch  from  the  cut  edge,  penetrating  obliquely  to  the  cut  surface. 
The  drill  should  be  slightly  larger  than  the  wire  to  be  used.  Silver 
wire  is  chosen  for  this  purpose.  The  piece  of  wire  is  inserted  through 
the  drill-holes,  including  in  this  way  a  portion  of  each  fragment,  the 
ends  are  brought  together  on  the  outside  of  the  bone  and  twisted  together 
with  heavy  forceps,  cut  short,  and  the  twisted  portion  hammered  down 
so  as  to  lie  close  against  the  bone.  Whether  one  or  more  points  on 
the  circumference  of  the  cut  bone  are  to  be  sutured,  and  where  the 
sutures  are  to  be  placed,  must  be  matters  of  judgment  in  each  individ- 
ual case. 

The  question  of  the  advisability  of  using  wire  sutures  at  all  is  to- 
day a  moot  point.  On  the  whole,  the  practice  seems  to  have  little 
actual  evidence  to  support  it.  It  is  obvious  that,  even  when  freshly 
placed,  sutures  of  this  sort  are  a  very  imperfect  mode  of  fixation  ;  and 
when  we  consider  that  the  presence  of  the  wire  determines  absorption 
of  the  bone  about  it,  with  consequent  loosening,  it  becomes  clear  that  the 
wire,  if  useful  at  all,  can  act  only  to  prevent  lateral  displacement.  Whether 
this  might  not  equally  well  be  attained  with  other  sutures  is  a  question. 
It  is  true  that  there  should  be  no  danger  from  sepsis  from  the  wire, 
and  its  presence  is  often  entirely  unnoticed  by  the  patient  for  long 
periods  of  time.  In  other  cases,  on  the  other  hand,  the  wire  unques- 
tionably acts  as  a  foreign  body,  and  causes  irritation,  late  suppuration, 
and  sloughing  of  the  skin  over  it.  These  cases  are  particularly  trouble- 
some because  of  the  difficulty  of  removing  the  wire,  especially  when 
it  has  been  long  embedded. 

Apart  from  these  considerations,  the  influence  of  the  presence  of 
the  wire  on  the  process  of  repair  is  more  than  doubtful.  It  is  known 
that  suppuration  and  necrosis  may  result,  and  that  the  wire  causes 
some  bone-rarefaction  in  its  immediate  vicinity.  It  seems  only  fair  to 
assume  that  it  must  act  to  some  extent  as  an  irritant,  and  in  many 
cases  at  least  be  prejudicial  to  union  of  the  fragments. 

From  the  standpoint  of  actual  results,  moreover,  it  may  be  said 
that  simple  resection,  with  proper  and  efficient  immobilization  of  frag- 
ments, yields  as  good  results  as  wiring. 


3§4 


RXTERXATIONAL    TEXT-BOOK  OF  SURGERY. 


Bxcision  of  the  Upper  Jaw  (Figs.  127-129"). — This  operation, 
formally  carried  out,  is  practically  limited  to  cases  of  new  growths. 
Partial  excision  may  be  performed  for  a  variety  of  causes,  more  espe- 
cially for  necrosis  of  the  jaw. 

Osteoplastic  resections,  so  called,  in  which  the  portion  temporarily 
displaced  is  not  separated  from  the  soft  parts  and  is  subsequently 
replaced,  may  be  performed  in  cases  of  nasopharyngeal  polypus,  etc., 
when  more  room  is  needed  than  is  afforded  through  the  natural 
openings. 

For  the  complete  operation  there  are  several  methods  of  gaining 
access  to  the  parts  to  be  divided,  all  aiming  at  a  minimum  of  displace- 
ment by  the  external  incision,  as  well  as  at  ease  of  access. 

The  bones  to  be  divided  in  removing  the  whole  of  the  upper  jaw 
are:  a,  the  nasal  portion  of  the  superior  maxilla;  />,  the  external  por- 
tion of  the  maxilla,  or,  more  usually,  the 
malar  bone  itself  just  outside  the  junction ; 

c,  the  orbital  plate  divided  in  combination 
with  the  cuts  dividing  a  and  b  (Fig.  127); 

d,  the  median  connection  from  the  teeth 
to  the  soft  palate.  These  points  are  di- 
vided in  much  the  same  way  in  all  de- 
scribed methods. 

The  primary  danger  of  the  operation 
is  from  hemorrhage,  and  temporary  liga- 
tion of  the  external  carotid  has  been  em- 
ployed to  lessen  bleeding.  It  is  not,  how- 
ever, usually  done.  The  free  hemorrhage 
involves  much  trouble  in  some  cases  from 
inspired  blood,  and  some  operators  have 
preferred  to  do  tracheotomy  and  use  Tren- 
delenburg's tampon-cannula,  or,  still  bet- 
ter, insert  a  tracheotomy  tube  and  plug 
the  throat  from  above.  Rose's  position 
has  also  been  employed.  None  of  these 
measures  is  absolutely  necessary,  and  it 
must  depend  on  the  case  whether  they  are  of  sufficient  value  to  make 
up  for  their  disadvantages,  or  whether  the  operator  will  depend  on 
ready  and  accurate  sponging. 

By  Median  Incision. — The  typical  incision  for  the  operation  is  the 
median  (Fig.  128,  a).  This  starts  from  a  point  a  little  below  the  inner 
canthus,  runs  down  alongside  the  nose,  crosses  to  the  middle  of  the 
lip,  and  is  thence  carried  down  in  the  median  line,  the  lip  being  split 
through.  The  coronary  arteries  may  then  be  secured,  and  the  sec- 
ond incision  carried  from  the  upper  end  of  the  first  incision  outward 
along  the  lower  edge  of  the  orbit.  The  soft  parts  are  then  stripped 
back  from  the  bone  and  the  vessels  secured.  The  nasal  cartilages  are 
freed  from  the  bone,  and  the  nasal  process  cut  through  with  chisel  or 
cutting-forceps.  The  orbital  plate  is  then  divided  subperiosteal^'  on  the 
same  line,  the  division  being  carried  back  to  the  sphenomaxillary  fissure. 
The  next  cut  divides  the  malar  bone,  and  in  line  with  it  the  orbital 
floor  is  again  divided.     The  knife  will  suffice  for  this  division.     The 


FIG.  127. — Lines  of  section  of  bone 
in  excision  of  the  upper  jaw  :  abed, 
typical  total  resection ;  fihgjk,  Ol- 
lier's  operation;  abfg,  Guerin's 
operation;  cdlm,  removal  of  max- 
illa below  orbital  foramen. 


OSTEOTOMY. 


o°) 


soft  palate  is  separated  from  the  hard  with  the  knife  or  the  thermo- 
cautery, the  mucous  membrane  and  periosteum  of  the  palate  are  cut 
to  the  bone,  an  incisor  tooth  is  drawn,  and  the  whole  bony  median 
connection  is  severed  with  the  chisel  or  saw  close  to  the  nasal  septum. 
The  flap,  consisting  of  the  soft  parts  of  the  face,  is  then  dragged  back 
till  the  soft  parts  can  be  cut  back  of  the  jaw  as  far  as  the  pterygoid 
plate.  The  jaw  can  now  be  seized  and  wrenched  down  and  outward, 
tearing  it  loose  from  its  pterygoid  attachment.  The  bleeding  is 
checked  as  far  as  possible,  the  cavity  packed,  and  the  incision  closed 
by  sutures. 

Subperiosteal  Excision  of  Oilier. — The  incision  is  made  from  a 
point  on  the  lip  just  away  from  the  corner  of  the  mouth  and  carried 
up  to  the  middle  of  the  malar  bone ;  or  the  operation  may  be  per- 
formed throucrh  the  usual  median  incision.     The  mucous  membrane  of 


-^ 

&- 

\     **~ 

\  » 

\ 

V 

- 

J 

...-'  ' 

FIG.  128. — a,  Median  incision  for  excision 
of  the  upper  jaw ;  b,  external  incision  for  the 
same  operation. 


Fig.  129. — a,  Incision  for  Ollier's  sub- 
periosteal excision  of  the  upper  jaw  ;  b,  incis- 
ion for  Guerin's  operation. 


the  mouth  is  then  cut  from  a  point  opposite  the  lateral  incision,  and 
carried  close  to  the  gum  around  back  of  the  last  tooth  ;  then  for- 
ward again,  close  to  the  gum  on  the  inner  side,  opposite  the  point 
of  beginning.  From  the  beginning  of  this  incision  the  periosteum  is 
cut  obliquely  to  a  point  just  opposite  the  nostril.  Beginning  with  this 
cut,  the  periosteum  is  stripped  up  till  it  has  been  raised  from  the  whole 
front  surface  of  the  bone  and  from  the  whole  orbital  floor.  The  peri- 
osteum of  the  roof  of  the  mouth  is  then  freed,  beginning  with  the 
incision  described,  and  working  to  the  median   line. 

The  nasal  and  malar  processes  are  then  cut  through,  as  in  the 
usual  procedure ;  but  instead  of  cutting  in  the  median  line,  this  opera- 
tion leaves  in  situ  a  wedge  of  bone  bearing  the  incisor  teeth,  the  bone- 
cuts  running  from  the  socket  of  the  extracted  canine  tooth  obliquely 
upward  to  the  nostril  and  obliquely  backward  to  the  median  line, 
thence  directly  backward  to  the  soft  palate. 

After  removal  of  the  bone,  the  periosteal  flaps  from  the  roof  of  the 


386  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

mouth  and  from  the  front  of  the  bone  are  sutured  together  and  the 
external  wound  sutured. 

Excision  of  the  Upper  Portion  of  the  Superior  Maxilla. — This 
operation  aims  at  leaving  the  whole  alveolar  process  in  situ,  while 
removing  the  diseased  upper  portion  of  the  jaw.  The  same  incision 
is  used  'as  for  total  resection,  and  the  soft  parts  are  dissected  up 
and  reflected  in  the  same  way.  The  periosteum  of  the  orbital  floor 
is  stripped  up  in  its  whole  extent,  and  the  nasal  and  malar  processes 
divided  and  the  orbital  plate  cut  in  the  typical  way.  The  isolation  of 
the  piece  to  be  removed  is  then  accomplished  by  a  horizontal  saw-cut 
from  the  nostril  outward,  passing  above  the  teeth.  This  portion  of  the 
jaw  is  then  pried  or  wrenched  out  of  its  bed  and  removed,  leaving  the 
alveolar  process  intact. 

Excision  of  the  Lower  Portion  of  the  Superior  Maxilla  {Gueriri). 
— The  incision  for  this  operation  runs  from  the  ala  of  the  nose  to  the 
corners  of  the  mouth,  following  the  nasolabial  fold.  The  flap  so  out- 
lined is  dissected  up,  the  mucous  membrane  being  incised  along  the 
saw ;  the  alveolar  process  is  laid  bare,  and  an  opening  made  into  the 
nostril  from  in  front.  A  fine  saw  is  then  introduced  into  the  nasal 
cavity,  and  the  bone  divided  horizontally  outward  above  the  roots  of 
the  teeth,  from  the  nostril  to  the  lower  edge  of  the  malar  bone,  or 
through  the  malar  process.  The  soft  palate  is  next  detached  from  the 
hard  by  a  transverse  incision,  one  of  the  incisor  teeth  extracted,  and 
the  median  connection  severed  with  chisel  or  saw.  The  portion  included 
between  these  cuts  is  then  wrenched  down  and  out  (Fig.  129). 

Resection  of  the  Posterior  Part  of  the  Hard  Palate  for  Removal 
of  Nasopharyngeal  Polyps. — This  operation  gives  a  limited  access  to 
the  nasopharynx  by  temporarily  clearing  away  the.roof  of  the  mouth. 
For  its  performance  the  mouth  is  widely  opened  with  a  gag,  and  an 
incision  made  which  splits  the  soft  palate  centrally  for  its  full  depth 
(see  Fig.  130),  and  extends  forward  for  about  half  the  depth  of  the 
hard  palate.  From  the  anterior  end  of  the  incision  transverse  cuts  are 
carried  outward,  outlining  a  flap  on  either  side,  which  is  then  dissected 
up  subperiosteally.  The  square  of  hard  palate  thus  denuded  is  then 
chiselled  out  or  removed  with  the  saw  or  forceps.  After  the  polyp  is 
removed  the  soft  parts  are  replaced,  and  the  median  incision  closed  as 
for  a  staphylorrhaphy. 

Osteoplastic  Resection  of  the  Anterior  Portion  of  the  Palate  for 
the  Removal  of  Nasopharyngeal  Polyps. — The  attachment  of  the 
upper  lip  to  the  bone  from  one  bicuspid  tooth  to  the  other  is  divided, 
thus  allowing  the  nasal  cavities  to  be  open  from  the  front.  The  canine 
teeth  are  then  removed,  and  an  incision  is  made,  extending  from  each 
canine  fossa  to  the  posterior  border  of  the  palate,  through  the  mucous 
membrane  and  periosteum  of  the  hard  palate.  The  alveolus  and  hard 
palate  are  then  divided  by  a  chisel  along  these  lines.  The  nasal  mucous 
membrane  is  divided,  and  this  mass  is  turned  back  on  the  velum  as  on 
a  hinge,  admission  thus  being  gained  to  the  upper  pharynx.  After  the 
removal  of  the  tumor  the   resected  portion  is  sutured  in  place  (Fig. 

130). 

Resection  of   the  Upper  Portion  to  Facilitate  Removal  of    Naso= 

pharyngeal  Polyps,  leaving  the  Hard  Palate  and  Alveolar  Process 


OSTEOTOMY. 


387 


{von  La?igenbeck). — In  von  Langenbeck's  operation  two  incisions  are 
made,  making  two  sides  of  a  triangle  on  the  face,  with  the  base  toward 
the  nose.  One  incision  starts  from  the  ala  of  the  nose,  and,  curving 
slightly  downward,  ends  on  the  zygoma ;  the  other,  starting  from  the 
side  of  the  nose,  follows  the  floor  of  the  orbit  and  nose  to  the  first 
incision  at  about  the  middle  of  the  malar  bone. 

The  soft  parts  and  periosteum  are  disturbed  as  little  as  possible, 
except  along  the  floor  of  the  orbit,  where  the  periosteum  is  lifted  from 
the  bone  as  far  back  as  the  sphenomaxillary  fissure.  The  origin  of  the 
masseter  is  then  cut  where  it  appears  in  the  incision.  A  director  is 
now  passed  to  the  outer  wall  of 
the  nasal  cavity,  passing  under  the 
zygoma  and  through  the  pterygo- 
maxillary  fissure.  A  finger  in  the 
mouth  can  detect  the  end  of  the 
director.  The  director  is  with- 
drawn, and  a  fine  saw,  edge  up,  is 
passed  along  this  line.  The  malar 
portion  of  the  zygoma  is  cut  across. 
Passing  through  the  sphenomaxil- 
lary fissure,  the  floor  of  the  orbit 
is  divided,  the  incision  ending  just 
short  of  the  lacrimal  bone.  The 
saw  is  then  removed  and  introduced 
through  the  pterygomaxillary  fis- 
sure, edge  downward.  The  walls 
of  the  antrum  are  divided,  following 
quite  closely  the  cutaneous  incis- 
ion, and  the  lower  part  of  the  ante- 
rior nares  is  entered.  An  elevator 
is  now  introduced  into  the  pterygo- 
maxillary fissure,  and  the  separated  portion  of  the  maxilla,  with  the 
covering  of  skin  and  periosteum,  is  pried  toward  the  middle  line,  up- 
ward and  inward.  This  fragment  receives  the  blood-supply  through 
the  soft  parts  at  the  base  of  the  triangle  on  the  side  of  the  nose.  As 
the  bones  of  the  nose  are  not  much  disturbed  by  the  operation,  at  its 
close  the  resected  portion  can  usually  be  held  in  position  by  cutaneous 
sutures  and  pressure.  No  drainage-tube  is  required.  The  disadvan- 
tages of  the  operation  are  its  difficulty,  resulting  paralysis  from  division 
of  the  branches  of  the  facial  nerve,  and  occasionally  injury  to  the  lac- 
rimal duct. 

Bxcision  of  the  Inferior  Maxilla. — The  whole  or  any  portion 
of  the  lower  jaw  may  be  removed.  The  incision  will  depend  on  the 
extent  and  situation  of  the  part  to  be  excised.  It  may  lie  entirely 
within  the  mouth,  or  externally  along  the  lower  border,  and,  if  neces- 
sary, along  the  ramus  of  the  jaw.  The  following  anatomical  relations 
are  of  importance  :  The  internal  maxillary  artery  runs  forward  beneath 
the  ramus  of  the  jaw  and  along  the  lower  border  of  the  external 
pterygoid  muscle,  and  then  obliquely  upward  and  forward.  The  lin- 
gual nerve  runs  between  the  internal  pterygoid  muscle  and  the  ramus 
of  the  jaw.     Stenson's  duct  runs  about  a  finger's  breadth  below  the 


Fig.  130. — a  a  a  a.  Incision  in  resection  of 
back  part  of  the  hard  palate  ;  bb,  incision  in 
Ollier's  subperiosteal  jaw-resection. 


388 


INTERNATIONAL    TEXTBOOK  OF  SURGERY. 


zygoma,  with  the  facial  nerve.  The  facial  artery  crosses  the  lower 
border  of  the  jaw,  at  the  anterior  margin  of  the  masseter  muscle. 
Division  of  the  attachments  of  the  geniohyoglossus  muscles  to  the 
bone  deprives  the  tongue  of  its  support  and  permits  it  to  fall  back 
upon  the  glottis.  Therefore  it  may  be  necessary  to  pass  a  suture 
through  the  tongue.  At  the  close  of  any  form  of  resection  the  buccal 
mucous  membrane  and  deeper  tissues  should  be  sutured,  and  any 
drainage  that  is  necessary  done  from  outside. 

Resection  of  the  Anterior  Portion  of  the  Body. — This  may  be 
accomplished  by  any  one  of  the  following  incisions  :  A  vertical  one  in 
the  median  line  of  the  lip,  a  curving  incision  under  the  lower  border 
of  the  chin,  or  an  incision  inside  the  mouth.  Whatever  the  incision, 
the  bone  is  cleared  of  muscular  attachments,  two  teeth  drawn  at  the 
limits  of  the  portion  which  it  is  proposed  to  excise,  the  bone  sawed 
through,  and  the  ends  drawn  together  and  fastened. 

Resection  of  the  Lateral  Portion  of  the  Body. — The  incision  starts 
from  the  angle  of  the  jaw,  and,  following  the  facial  border,  extends  to 
the  symphysis,  where  it  turns  upward  to  the  base  of  the  lower  lip. 
The  lip  need  not  be  divided  entirely.  The  periosteum  may  or  may  not 
be  lifted,  as  is  desired.  The  bone  is  cleared  not  quite  to  the  median 
line,  so  as  not  to  disturb  the  attachments  of  the  geniohyoglossus  mus- 
cle, and  sawed  through  at  this  point,  after  a 
tooth  has  been  drawn,  if  it  is  necessary. 
The  soft  parts  are  scraped  away  from  the 
bone  as  they  are  brought  into  view,  and 
pulled  downward  and  outward.  A  tooth  is 
drawn,  marking  the  posterior  limit  of  the 
part  to  be  removed,  and  the  bone  is  sawed 
through.  The  mucous  membrane  should 
be  accurately  adjusted,  that  healing  may 
occur  as  soon  as  possible.  As  soon  after 
the  operation  as  possible  an  apparatus 
should  be  worn  to  hold  the  remaining  half 
of  the  lower  jaw  in  proper  relation  to  the 
upper. 

Resection  of  the  Ramus  and  Half  of 
the  Body  (Fig.  131,  b). — The  incision,  be- 
ginning just  in  front  of  the  ear,  below  the 
inferior  edge  of  the  zygoma,  is  continued  to 
the  angle  of  the  jaw,  and  along  the  inferior 
border  of  the  ramus  to  \  inch  below  the 
symphysis,  where  it  meets  a  vertical  incision  coming  down  from  the 
middle  of  the  lower  lip.  The  flap  thus  marked  out  is  dissected  back,, 
and  the  facial  artery  tied.  According  to  the  nature  of  the  case,  the 
periosteum  may  be  removed  with  the  bone,  or  the  resection  may  be 
subperiosteal.  If  the  periosteum  is  to  be  removed  with  the  bone,  the 
operation  is  continued  by  drawing  a  tooth  and  dividing  the  bone  by  a 
saw.  Then,  pulling  the  jaw  forward  and  downward,  the  inner  surface 
of  the  bone  is  cleaned  of  soft  parts,  separating  the  mucous  membrane 
and  the  pterygoid  muscle.  The  inferior  dental  nerve  is  divided,  and 
the  insertion  of  the  temporal  muscle  to  the  coronoid  process  is  cut 


Fig. 


131. — Incision  for  resection 
of  the  lower  jaw. 


OSTEOTOMY.  389 

across.  Then,  after  separating  the  soft  parts  from  the  external  surface 
of  the  bone,  including  the  external  pterygoid,  the  condyle  is  twisted 
out  of  the  joint  and  the  bone  is  free. 

Resection  for  Ankylosis  of  the  Jaw. — Ankylosis  of  the  jaw 
may  be  due  to  contraction  following  severe  and  destructive  forms  of 
inflammation  where  the  trouble  is  not  limited  to  the  articular  surface, 
of  which  cancrum  oris  may  serve  as  a  type,  or  to  bony  or  fibrous 
union  of  the  condyle  and  temporal  bone.  The  first  form  of  ankylosis 
is  dealt  with  by  removing  a  wedge-shaped  piece  of  bone  from  the  hor- 
izontal ramus,  anterior  to  the  adhesions,  usually  in  front  of  the  masse- 
ter,  to  form  a  false  joint  at  this  point.  When  there  is  bony  union  of 
the  joint-surfaces  excision  of  the  condyle  is  indicated.  The  incision 
is  made  over  the  joint,  just  anterior  to  the  temporal  artery,  beginning 
at  the  lower  border  of  the  zygoma.  The  space  is  enlarged  by  a  hori- 
zontal cut  from  the  upper  end,  following  the  lower  edge  of  the  zygoma. 
This  flap  is  reflected  forward,  with  care  not  to  injure  the  facial  nerve. 
The  muscular  fibers  arising  from  the  zygoma  passing  over  the  joint 
are  separated  and  the  capsule  is  opened.  The  neck  of  the  condyle  is 
freed  and  divided  with  a  chisel,  and  then,  grasped  by  forceps,  is  twisted 
and  cut  free  from  the  bone.  During  the  operation  all  instruments 
should  be  kept  close  to  the  bone,  to  avoid  injuring  important  struct- 
ures. Some  temporary  facial  paralysis  may  follow  the  operation.  It 
is  important  that  passive  motion  should  be  begun  in  a  few  days  after 
either  operation,  and  should  be  regularly  practised.  Screw-gags  and 
graduated  pieces  of  cork  may  be  of  use  in  helping  the  patient  to  open 
his  mouth.  If  the  motions  cause  much  pain,  it  would  be  well  to 
administer  gas  or  some  anesthetic  to  the  patient  for  the  first  few  times. 
Unless  the  after-treatment  is  conscientiously  carried  out,  relapses  are 
likely  to  occur. 

Resection  of  the  Sternnm. — Fragments  of  the  sternum  have 
been  frequently  removed  for  shot  injuries,  with  very  slight  mortality. 
If  the  periosteum  can  be  left,  new  bone  quickly  forms.  The  incision 
is  vertical  or  crucial,  depending  on  the  amount  of  bone  to  be  removed. 
At  times  it  may  be  advantageous  to  use  a  trephine  before  taking  a 
gouge  or  chisel.  The  structures  lying  close  to  the  posterior  surface 
of  the  sternum  must  be  carefully  avoided.  The  costal  cartilages  may 
be  divided  with  a  strong  scalpel,  and  the  sternum  itself  with  a  saw. 

Resection  of  the  Ribs. — The  incision  follows  the  curve  of  the 
middle  of  the  rib  to  be  resected.  Its  extent  corresponds  to  the  amount 
of  rib  to  be  removed.  The  incision  is  carried  down  to  the  bone,  and 
the  periosteum  is  separated  from  the  rib  from  behind,  as  well  as  from 
the  front,  by  a  blunt  dissector  ;  or,  if  this  is  impossible,  the  rib  is  scraped 
free  from  soft  parts.  The  intercostal  artery,  which  lies  in  the  groove 
in  the  inferior  border  of  the  rib,  must  be  avoided,  and  the  desired 
amount  of  bone  cut  away  with  bone-forceps,  care  being  taken  not  to 
injure  the  costal  pleura.  If  portions  of  several  ribs  are  to  be  excised, 
the  original  incision  can  be  enlarged  by  vertical  cuts  at  either  end. 

For  long-standing  cases  of  empyema  in  which -there  is  a  large  cavity 
between  a  retracted  lung  and  a  rigid  chest-wall,  Estlander  devised  a 
tlwracoplastic  method  of  filling  up  this  cavity.  To  obliterate  this  space, 
the  chest-wall  is  made  to  sink  in  by  simply  dividing  some  of  the  ribs  or 


390  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

by  removing  portions  of  them.  Each  case  has  to  be  considered  some- 
what by  itself,  and  the  incision  is  made  in  such  a  way  as  to  allow  the 
greatest  amount  of  sinking  in  of  the  chest-wall.  Ordinarily  the  inci- 
sions form  two  sides  of  a  very  acute  triangle,  the  base  being  up,  and  are 
wide  enough  apart  to  permit  removal  of  sufficient  portions  of  the  ribs ; 
or  a  horizontal  incision  along  a  rib,  with  a  vertical  one  rising  from  its 
middle,  will  open  up  the  same  area.  The  lower  rib  is  usually  first 
removed  subperiosteally,  and  the  side  examined  to  determine  the 
amount  of  the  other  ribs  necessary  to  take  out.  The  process  is  the 
same  for  each  rib.  Any  bleeding  from  the  intercostal  arteries  can  easily 
be  controlled.  In  Schede's  operation  portions  of  the  thickened  costal 
pleura  are  also  removed  to  permit  more  complete  sinking  in  of  the 
chest-wall.  These  operations  nowadays  are  scarcely  justifiable,  as  the 
contraction  of  the  side  produces  extremely  severe  forms  of  lateral 
curvature. 

Bxcision  and  Resection  of  the  Clavicle. — The  clavicle  lies  so 
near  to  the  important  structures  in  the  neck  that  operations  on  it  have 
been  attended  with  some  risk.  When  the  normal  relation  of  the  parts 
has  been  destroyed,  as  by  morbid  growths,  the  excision  of  this  bone 
may  prove  a  very  serious  operation.  When  the  periosteum,  however, 
has  been  loosened  by  an  osteitis,  it  is  quite  simple.  The  subperiosteal 
method  gives  the  best  results.  The  scapular  extremity  is  broad  and 
flat,  and  is  exposed  by  a  curved  incision  with  its  convexity  forward  and 
a  little  outward.  The  bone  is  well  exposed  by  turning  back  this  flap. 
If  the  periosteum  cannot  be  separated,  the  muscular  attachments  of 
the  deltoid,  pectoralis,  trapezius,  and  sternomastoid  are  divided,  the 
joint  opened,  and  the  end  of  the  clavicle  removed.  The  sternal  extrem- 
ity is  removed  by  an  incision  over  the  sternal  end,  curving  downward, 
the  flap  is  raised,  and  a  saw  slipped  under  the  bone  where  it  is  to  be 
divided.  After  it  has  been  cut,  the  muscular  attachments  are  to  be 
divided  and  the  bone  disarticulated.  The  incision  for  removal  of  the 
clavicle  as  a  whole  runs  along  the  lower  border  of  the  bone,  and,  if 
necessary,  may  be  enlarged  by  a  vertical  incision  at  its  ends.  The  bone 
is  freed  all  around  as  much  as  possible,  and  the  acromial  end  raised ; 
then,  separating  the  periosteum  on  the  anterior,  inferior,  and  posterior 
surfaces,  or  the  muscles,  as  the  case  may  be,  and  dividing  the  ligaments, 
posterior,  inferior,  and  superior,  the  clavicle  is  lifted  up  until  the  sternal 
end  is  disarticulated.  The  risk  of  wounding  the  vessels  of  the  neck, 
the  pleura,  or  the  thoracic  duct  is  reduced  to  a  minimum  by  keeping 
close  to  the  bone  and  always  cutting  against  it,  and  by  raising  the 
acromial  end,  as  in  the  method  described,  thus  giving  more  space  when 
the  important  structures  are  approached. 

Excision  and  Resection  of  the  Scapula. — Where  removal  of 
but  a  portion  of  the  scapula  is  required,  no  definite  rules  can  be  laid 
down  for  the  excision.  The  operator  must  be  guided  in  making  his 
cuts  by  the  amount  to  be  taken  away.  Usually  the  operation  for  the 
removal  of  the  whole  of  the  scapula  follows  the  method  devised  by 
Oilier.  The  scapula  is  well  exposed  by  placing  the  patient  on  his 
sound  side,  close  to  the  edge  of  the  table.  An  incision  is  made  along 
the  whole  length  of  the  spine  of  the  scapula.  Two  other  incisions  begin 
from  its  posterior  end,  one  following  the  posterior  border  to  the  inferior 


OSTEOTOMY.  39 1 

angle,  the  other  upward  and  forward  for  a  short  distance.  The  flaps 
are  turned  back,  and  the  muscular  attachments  of  the  trapezius  and 
deltoid  are  divided.  The  vertebral  border  is  then  made  prominent  by 
drawing  the  patient's  hand  over  the  shoulder  on  the  sound  side.  The 
periosteum  is  divided  between  the  rhomboideus  and  the  infraspinatus, 
and  the  infraspinous  fossa  carefully  cleaned.  The  teres  major  and  ser- 
ratus  magnus  are  then  detached,  freeing  the  inferior  angle,  which  is 
then  lifted  up,  and  the  subscapulars  muscle  is  dissected  off  from  below 
upward.  The  supraspinous  fossa  is  then  cleared,  injury  to  the  supra- 
scapular nerve  being  avoided  by  lifting  it  with  the  periosteum.  The 
remaining  part  of  the  bone  is  cleared,  working  forward  to  the  neck  of 
the  scapula,  which  is  divided  with  a  chain-saw  or  forceps.  The  attach- 
ments of  the  acromion  to  the  clavicle,  including  the  conoid  and  trape- 
zoid ligaments,  are  then  cut  and  the  joint  opened.  The  muscles 
attached  to  the  coracoid  process  are  divided  and  the  process  twisted 
free.  The  great  risk  through  the  operation  is  from  hemorrhage,  espe- 
cially as  the  excision  is  usually  undertaken  for  removal  of  a  sarcoma, 
under  which  conditions  the  vessels  are  numerous  and  of  large  size.  It 
is  advisable  to  have  compression  over  the  subclavian  artery ;  and  in 
some  cases  it  may  be  necessary  to  make  a  small  incision  over  the  vessel, 
in  order  better  to  control  the  bleeding.  The  main  vessels  may  be 
exposed  and  ligatured  before  cutting. 

Excision  and  Resection  of  the  Humerus. — The  humerus  may 
be  removed  in  part  or  as  a  whole.  If  the  upper  part  is  to  be  excised, 
the  relation  of  the  musculospiral  nerve  must  be  remembered.  It  passes 
around  posterior  to  the  humerus  from  its  inner  side,  lies  close  to  the 
bone  in  the  musculospiral  groove,  and  passes  down  to  the  outside  of 
the  arm  between  the  brachialis  anticus  and  supinator  longus.  If,  for 
any  reason,  the  incision  must  be  on  the  outer  side  of  the  arm,  it  is  well 
first  to  find  the  nerve  and  retract  it  to  the  outside  before  going  on  with 
the  incision.  The  incision  for  excision  of  the  head  of  the  humerus  is 
usually  that  of  Oilier — a  straight  cut  over  the  surface  of  the  joint, 
beginning  at  the  acromioclavicular  junction  and  passing  over  the  ante- 
rior convexity  of  the  joint  for  a  distance  of  3  or  4  inches.  The  peri- 
osteum is  saved  as  much  as  possible,  the  joint  opened,  and  the  muscu- 
lar attachments  at  the  tuberosities  divided  as  they  are  brought  into  view 
by  rotating  the  arm.  It  is  advisable  at  times  to  leave  as  much  of  the 
tuberosities  as  possible,  as  the  formation  of  new  bone  is  then  better. 
The  head  of  the  bone  is  forced  out  of  the  incision  and  the  bone  sawed 
across.     The  best  result  comes  from  dividing  it  at  the  anatomical  neck. 

The  Lower  Portion. — The  structures  most  likely  to  be  injured,  and 
therefore  to  be  avoided,  at  the  lower  end  are  the  brachial  artery  and 
ulnar  nerve.  The  incision  is  made  between  the  triceps  and  supinator 
longus,  avoiding  the  musculospiral  nerve,  and  the  steps  of  the  operation 
are  then  similar  to  those  in  excision  of  the  elbow.  The  whole  humerus 
may  be  resected,  care  being  taken  to  leave  the  periosteum,  as  on  it 
depend  the  formation  of  new  bone  and  the  usefulness  of  the  arm. 

Excision  and  Resection  of  the  Ulna. — As  the  ulna  is  compara- 
tively superficial  in  its  whole  extent,  it  is  easily  removed.  The  incision 
follows  its  posterior  border,  and  at  the  upper  end  runs  obliquely 
upward  and  outward  between  the  triceps  and  anconeous  muscles.    The 


392  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

subperiosteal  method  is  to  be  pursued  if  possible.  When  the  whole 
bone  is  to  be  excised,  the  upper  end  and  the  olecranon  are  first  dis- 
sected free,  and  the  bone  is  then  divided  at  its  middle  point.  This  per- 
mits removal  of  the  proximal  half.  The  distal  portion  is  then  removed. 
The  dorsal  branch  of  the  ulnar  nerve  winds  backward  beneath  the 
flexor  carpi  ulnaris  about  2  or  3  inches  above  the  wrist,  and  should  be 
saved  when  possible. 

Bxcision  and  Resection  of  the  Radius. — The  incision  lies  on 
the  external  surface  of  the  radius,  parallel  to  its  long  axis.  It  extends 
from  the  styloid  process  to  the  radiohumeral  articulation.  The  inter- 
space between  the  supinator  longus  and  the  extensor  carpi  radialis 
longior  muscles  is  found.  Following  through  this  intermuscular  space 
the  radial  nerve  is  found,  which  runs  beneath  the  supinator  longus  to 
about  3  inches  above  the  wrist,  where  it  turns  backward  and  becomes 
subcutaneous.  The  supinator  brevis  is  divided  and  the  periosteum 
separated.  The  bone  is  then  sawed  through  in  the  middle  and  each 
piece  removed  separately.  In  young  persons  the  restoration  of  parts 
after  subperiosteal  resection  of  the  ulna  or  radius  especially  has  been 
good.  On  the  other  hand,  when  the  periosteum  has  not  been  saved  or 
the  epiphyses  destroyed,  the  deformities  have  been  great.  For  excision 
of  only  a  portion  of  the  radius  an  incision  along  the  same  line  is  used. 

Excision  of  the  Metacarpal  Bones  and  Phalanges. — To 
reach  a  metacarpal  bone  a  longitudinal  incision  on  the  dorsum  is  used. 
At  the  first  cut  the  skin  alone  is  divided,  as  the  extensor  tendons  lie 
on  the  dorsal  aspect  of  the  metacarpals.  These  tendons  are  pulled 
aside,  the  periosteum  freed,  and  a  curved  director  slipped  under  the 
bone,  lifting  it  up.  The  bone  is  then  divided  with  cutting-forceps.  The 
end  is  seized  with  bone-forceps  and  twisted  free.  If  the  whole  bone  is 
to  be  removed,  the  remaining  half  is  dealt  with  in  the  same  way.  Ex- 
cision of  the  metacarpophalangeal  joint  of  a  finger  is  apt  to  leave  a 
flail-like  finger.  However,  excision  of  the  metacarpophalangeal  joint 
of  the  thumb  has  given  excellent  results. 

When  a  phalanx  is  to  be  resected,  the  incision  lies  on  the  side  of  the 
finger  nearer  the  dorsal  than  the  palmar  surface,  to  avoid  the  vessels 
and  nerves.  To  remove  a  terminal  phalanx  a  U-shaped  incision  is 
made,  the  arms  of  the  U  being  on  the  sides  of  the  phalanx,  and  the 
curve  on  the  dorsum  close  to  the  nail. 

Resection  of  the  Bones  of  the  Pelvis. — It  is  seldom  that  the 
attempt  is  made  to  excise  much  of  the  pelvis.  The  operation  is  under- 
taken usually  to  remove  small  areas  of  bone.  However,  C.  Nelaton 
reports  a  case  in  which  he  removed  the  whole  ilium,  and  the  patient 
preserved  the  power  of  walking.  If  the  ischium  with  its  descending 
ramus  and  the  pubis  are  involved,  an  incision  is  made,  starting  from 
the  genitocrural  fold,  along  the  rami  of  the  ischium  and  pubis  to  the 
body  of  the  pubis.  The  periosteum  is  lifted  from  the  parts  to  be 
removed  and  the  diseased  bone  cut  out.  If  much  of  the  ilium  is  in- 
volved, the  incision  follows  the  crest  of  the  ilium  from  the  posterior 
superior  spine  to  the  anterior  superior  spine,  and  then  turns  sharply 
downward  and  backward  to  the  region  of  the  trochanter.  The  peri- 
osteum, reached  along  the  crest  of  the  ilium  between  the  sets  of  mus- 
cles, is  raised  from  the  inner   surface,  extending  down  into  the  iliac 


OSTEOTOMY.  393 

fossa,  as  well  as  from  the  outer.  As  much  of  the  diseased  bone  as  is 
desired  is  removed  by  the  chisel  or  gouge.  This  operation  in  the 
hands  of  Kocher  and  Roux   has  given  good  results. 

Hxcision  of  the  Coccyx. — The  coccyx  may  require  removal  in 
whole  or  in  part  for  necrosis,  fracture,  or  the  painful  affection  coccygo- 
dynia,  and  as  the  preliminary  step  in  Kraske's  operation  for  excision 
of  the  rectum.  After  determining  the  limits  of  the  bone  by  the  finger 
in  the  rectum,  a  longitudinal  incision  is  made  over  the  middle  of  the 
coccyx,  extending  from  a  little  above  its  upper  limits  to  a  little  below 
its  tip.  If  necessary,  a  transverse  cut  may  be  made.  The  bone  is 
freed  from  soft  parts  and  the  articulation  with  the  sacrum  opened,  the 
sacrococcygeal  ligaments  divided,  and  the  bone  cut  free,  clearing  the 
anterior  aspect  as  it  is  raised. 

•  Resection  of  the  Shaft  of  the  Femur. — Excisions  of  portions 
of  the  shaft  of  the  femur  are  very  rare,  except  for  the  removal  of  large 
sequestra.  The  bone  is  reached  by  a  long  incision  on  the  outer  side 
of  the  leg.  The  space  between  the  vastus  externus  and  the  short  head 
of  the  biceps  is  found  and  followed  down  to  the  bone,  which  is  then 
entirely  freed  from  the  soft  parts  on  all  sides  if  possible,  and  divided  by 
a  saw  at  its  middle.  Each  end  can  then  in  turn  be  lifted  out  of  the 
wound,  and  the  proper  amount  cut  away.  In  the  after-treatment  ex- 
tension is  necessary  for  some  time,  to  prevent  excessive  shortening  of 
the  leg. 

Resection  of  the  Shaft  of  the  Tibia. — The  tibia  is  more  often 
excised  than  any  other  long  bone  in  the  body.  If  the  operation  is 
done  subperiosteally  and  the  periosteum  is  not  injured,  new  bone 
readily  forms  and  a  useful  leg  is  obtained.  The  incision  for  removal 
of  the  diaphysis  is  made  along  the  subcutaneous  surface  of  the  shaft, 
lying  at  the  upper  end  behind  the  tendons  of  the  gracilis,  sartorius,  and 
semitendinosus.  The  periosteum  is  excised  along  this  same  line,  and 
separated  all  around  the  bone  if  possible.  A  chain-saw  is  then  passed 
under  the  shaft  and  the  bone  divided,  or  the  diseased  portion  is 
chiselled  out.  In  the  majority  of  cases  the  operation  is  done  to 
remove  sequestra  resulting  from  osteomyelitis  or  the  necrosed  frag- 
ments following  a  compound  fracture.  If  the  incision  must  be  on  the 
outer  aspect  of  the  leg,  it  should  be  just  a  little  external  to  the  crest 
of  the  tibia.  The  tibialis  anticus  should  be  lifted.  The  periosteum  is 
not  injured.  If  the  posterior  surface  must  be  reached,  the  incision  is 
made  along  the  inner  border,  the  upper  end  of  the  cut  lying,  as  already 
described,  behind  the  tendons  of  the  gracilis,  sartorius,  and  the  semi- 
tendinoses,  and  the  muscles  raised  intact  with  the  periosteum.  When 
a  portion  of  the  tibia  is  removed  entirely,  so  that  there  is  a  space  left 
between  the  ends,  it  is  well  to  excise  a  corresponding  length  of  the 
fibula  to  bring  the  ends  in  contact. 

Resection  of  the  Fibula. — Excision  of  the  fibula  yields  very 
good  functional  results.  There  is  no  particular  method  of  proceeding. 
A  straight  incision  is  made  over  the  portion  to  be  removed,  and  is  con- 
tinued down  to  the  bone.  The  periosteum  is  divided  and  separated 
from  the  bone,  which  is  then  divided  by  a  saw  and  as  much  removed 
as  is  desired.  The  external  popliteal  nerve  is  to  be  avoided.  It  follows 
the  posterior  border  of  the  tendon  of  the  biceps,  winds  about  the  neck 


394  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

of  the  fibula,  and  divides  into  its  two  branches.  The  upper  articulation 
between  the  fibula  and  tibia  at  times  communicates  with  the  knee-joint, 
and  therefore  opening  this  articulation  should  be  avoided.  When  it  is 
necessary  to  remove  the  head,  it  should  be  chiselled  away  and  a  thin 
plate  of  bone  should  be  left  over  the  joint.  If  the  whole  fibula  is  to  be 
removed,  it  is  well  to  take  the  bone  out  in  two  parts,  as  the  peroneal 
muscles  would  be  cut  by  a  single  incision  the  length  of  the  bone. 
Therefore  a  separate  incision  is  made  for  the  lower  part  over  the 
anterior  external  aspect  of  the  bone,  and  another  over  the  upper 
portion. 

Excision  of  the  Bones  of  the  Foot. — The  tarsal  bones  are  re- 
moved principally  for  disease,  and  therefore  the  methods  are  largely 
atypical.  Each  case  has  to  be  considered  by  itself,  and  the  incision 
made  accordingly.  Disease  of  these  bones  usually  begins  in  the 
calcaneo-astragaloid  articulation,  attacking  first  the  calcaneum,  and 
later  the  astragalus.  Simple  scraping  away  of  the  diseased  portion 
does  not  compare  favorably  with  removal  through  the  entire  thickness 
of  the  bone. 

Calcaneum  (Fig.  132). — When  it  is  possible,  it  is  advisable  to 
leave  the  anterior  portion  of  the  os  calcis,  as  the  reproduction  of  bone 

is  better  in  these  cases  than 
where  the  whole  bone  is  re- 
moved. The  subperiosteal 
method  is  to  be  preferred 
over  those  in  which  the  en- 
tire bone  is  cut  away.  After 
the  subperiosteal  method  the 
reproduction  of  bone  is  at 
times  sufficient  to  give  a 
prominent  heel,  which  is  very 
serviceable  and  quite  as  firm 
as  the  sound  one.  The 
method  of  Faraboeuf  is  prob- 
ably the  best.  The  patient  is 
placed  on  the  sound  side  and 

Fig..  132. — Resection  of  the  calcaneum.  the  leg  supported  by  a  pillow, 

which  gives  free  access  to  the 
diseased  foot.  The  incision  begins  at  the  base  of  the  fifth  metatarsal, 
and  follows  the  external  surface  of  the  foot,  just  above  the  sole,  to  the 
heel,  which  it  circles,  and  then  passes  forward  on  the  inner  side  to  a 
point  opposite  its  origin.  A  second  incision  runs  from  this  upward 
along  the  external  border  of  the  tendo  Achillis  for  about  2  inches. 
The  two  flaps  are  raised.  The  periosteum  is  divided,  care  being  taken 
not  to  injure  the  peroneal  tendons,  which  lie  just  anterior  to  the  vertical 
cut.  The  periosteum  is  divided,  and  with  it  the  attached  ligaments  are 
raised,  first  on  the  outer  and  then,  after  cutting  the  insertion  of  the 
tendo  Achillis,  on  the  posterior  surface.  The  anterior  part  is  then 
freed  from  its  periosteum,  and  lastly  the  plantar  surface  is  cleared. 
The  anterior  portion  is  then  seized  with  lion-forceps  and  cut  free  as  it 
is  dragged  out. 

The  operation  for  removal  of  the  posterior  part  alone  is  more  sim- 


PLASTIC  SURGERY.  395 

pie.  The  incision  (Fig.  132,  a)  extends  to  the  periosteum,  which  is 
separated  from  the  bone  and  the  bone  sawed  across. 

Astragalus. — This  bone  is  excised  for  irreducible  dislocation  and 
caries  and  for  relief  of  some  forms  of  talipes,  and  is  the  first  step  in 
excision  of  the  ankle.  Two  incisions  may  be  made,  one  internal  and 
one  external ;  or  one  curving  incision  ma}'  run  across  the  dorsum  of 
the  foot.  The  outer  of  the  .two  incisions  lies  just  parallel  to  the  pero- 
neus  tertius,  beginning  a  little  above  the  level  of  the  articular  surface 
of  the  tibia.  A  second  cut  runs  from  the  middle  of  this  incision  back- 
ward to  just  below  the  tip  of  the  external  malleolus.  By  lifting  these 
two  flaps  the  bone  is  reached  between  the  peroneus  brevis  and  tertius. 
By  extending  and  inverting  the  foot  the  various  ligaments  are  exposed 
and  cut.  A  slightly  curved  incision  is  then  made,  running  forward  and 
backward  from  the  tip  of  the  inner  malleolus.  This  gives  access  to  the 
ligaments  on  the  inner  side  of  the  foot,  which  are  divided.  The  foot 
is  again  inverted  and  extended,  and  the  astragalus  grasped  by  forceps 
and  delivered  through  the  outer  wound. 

When  the  curved  incision  across  the  dorsum  of  the  foot  is  used  the 
cut  should  at  first  be  only  skin  deep.  The  various  tendons  on  the 
dorsum  of  the  foot  are  exposed  and  drawn  aside.  The  tendon  of  the 
extensor  brevis  is  divided,  and  the  structures  about  the  neck  and  the 
outer  non-articulating  surface  of  the  astragalus  are  cut  away.  The 
ligaments  within  reach  are  divided.  The  bone  is  grasped  and  drawn 
out,  and  the  remaining  ligaments  are  cut  as  they  are  reached. 

Metatarsal  Bones  and  Phalanges. — Resection  or  Excision. — The 
method  of  removing  the  phalanges  of  the  toes  corresponds  with  that 
of  removing  the  phalanges  of  the  fingers.  Lateral  incisions  are  usually 
employed.  The  value  of  the  great  toe  in  walking  should  be  remem- 
bered, and  when  a  diseased  bone  is  removed  from  it  the  periosteum 
should  be  left  as  far  as  possible,  to  provide  for  re-formation  of  bone. 
The  incision  for  removing  a  metatarsal  lies  along  the  dorsum.  The 
tendon  is  retracted  to  one  side  and  the  periosteum  divided.  The  pro- 
cedure is  similar  to  that  for  removing  the  metacarpals.  For  the  first 
and  fifth  metatarsals  the  incision  is  on  the  lateral  aspect,  curving  down- 
ward. 

PLASTIC  SURGERY. 

Plastic  surgery  is  concerned  with  the  repair  of  defects  or  losses  of 
tissue,  which  may  be  congenital,  or  have  resulted  from  disease  or  injury 
or  from  the  surgeon's  knife  in  the  removal  of  tumors,  etc.  By  far  the 
greater  number  of  plastic  operations  are  concerned  with  the  replace- 
ment of  skin-defects,  and  these  only  will  be  discussed  in  this  chapter. 

Methods  Employed  in  Plastic  Surgery. — Four  methods,  of 
which  the  first  three  include  the  great  majority  of  plastic  oper- 
ations, may  be  employed  for  the  repair  of  defects.  These  are : 
1.  The  method  of  directly  approximating  the  edges  by  stretching 
the  skin  and  deeper  parts  of  the  wound  together,  and  fixing  them  by 
sutures.  2.  The  method  of  approximating  the  edges  of  the  skin  after 
freeing  it  and  the  subcutaneous  tissue  from  underlying  tissues  ("  under- 
mining "  the  edges).  This  method  also  allows  the  use  of  subsidiary 
incisions  to  promote  lateral  displacement  or  sliding.     3.  The  method 


396 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


of  flap-formation,  and  revolution  of  the  flap  into  position  by  twisting 
the  pedicle  (the  so-called  "  Indian  "  method).  4.  The  method  of  trans- 
planting a  flap  from  a  distant  part  of  the  body,  as  from  the  arm  to  the 
nose,  and,  after  allowing  it  to  unite  around  the  greater  part  of  its  mar- 
gin, severing  the  pedicle  (the  so-called  "  Italian  "  method). 

1.  The  first  method,  or  direct  approximation  of  the  edges, 
may  be  applied  when  the  gap  is  small,  and  is  useful  for  the  closure  of 
sinuses  or  fissured  openings.  In  such  cases,  of  course,  careful  freshen- 
ing of  the  edges  is  required.  When  the  closure  of  small  raw  surfaces 
is  the  object,  the  shape  of  the  surface  makes  distinct  differences  as  to 
the  applicability  of  the  direct  method  of  closure.  An  elongated  rhom- 
boid or  ellipse  may,  of  course,  be  more  easily  approximated  to  a  single 
suture-line  than  a  square  or  circular  surface,  which  will  require  stretch- 
ing of  the  edges  across  half  the  diameter  of  the  surface.  A  small 
triangular  surface  may  be  easily  closed  by  diminishing  all  three  angles 
to  a  point  in  the  center,  or,  if  the  triangle  have  two  long  sides  and  a 
short  base,  by  directly  approximating  the  long  sides. 

2.  The  Method  of  lateral  Displacement  or  Gliding. — This 
method,  which  is  to  be  applied  whenever  direct  approximation  of  edges 


i  >S  M  %-% 


->< 


FIG.  133. — Repair  of  a  triangular  defect  (a  be)  by  means  of  a  bilateral  incision  (ad  and  bd'). 

would  result  in  disastrous  tension,  adds  to  the  former  method  the 
resources  of  freeing  the  flaps  and  making  subsidiary  incisions.  To 
close  a  triangle,  the  line  of  its  base  may  be  continued  by  an  incision, 


f  ^v 


Fig.  134. — Repair  of  a  triangular  defect  (a be)  by  means  of  a  curved  incision  {bd). 

and  the  flap  formed  by  the  base  and  the  adjacent  side  freed  and 
stretched  across  the  gap ;  or,  by  continuing  the  base-line  on  both  ends 
of  the  triangle,  two  flaps  may  be  freed  and  brought  together  in  the 
median  line  (Fig.  133). 


PLASTIC  SURGERY. 


397 


The  continuation  of  the  base-line  may  be,  under  some  circumstances, 
curved  rather  than  straight.  The  modification  known  as  von  Jacsche's 
operation  employs  the  curved  incision  for  this  purpose  (Fig.  134). 

Dieffcnbacli  closed  a  triangular  defect  by  displacing  a  quadrilateral 
flap  toward  one  side  of  the  triangle,  or  by  the  displacement  of  two 


•  ,/ 


Fig.  135. — Dieffenbach's  method  :  A,  a  triangular  defect  is  covered  by  a  laterally  displaced 
flap  (cabd) ;  the  triangle  bde  heals  by  granulation.  B,  the  defect  (abc)  is  to  be  repaired  by 
displacement  of  the  lateral  skin,  which  is  mobilized  by  the  incisions  ade  and  b  d'  e' . 

quadrilateral  .flaps  toward  the  middle  line  (Fig.  135,  ^4  and  B).  The 
triangle  left  by  displacement  of  the  flap  must  heal  by  granulation  or 
be  grafted. 

Biirow  devised  several  methods  for  the  closure  of  triangular  gaps, 
one  of  the  most  ingenious  of  which  is  shown  in  Fig.  136.     To  close 


FlG.  136. — Biirow's  operation  by  means  of  excision  of  lateral  triangles. 

the  triangle  at  abc,  the  incisions  ad  and  b d'  are  made,  and  the  flaps 
dac  and  d'bc  are  brought  together  in  the  middle  line.     Redundant 


X-rxi ;: 


■^'■k 


rrst  x 


Fig.  137. — Repair  of  a  quadrangular  defect  (abed)  by  means  of  the  incisions  ae,  be,  cf,  df. 


tissue  at  the  angles  maybe  made  by  excising  the  triangles  of  skin  ade 
and  e'b  d' '  and  it  will  be  found  that  when  the  two  sides  of  the  main 


39§ 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


triangle  are  sutured,  the  subsidiary  triangles  come  together  without 
tension. 

A  quadrilateral  gap  may  be  closed  by  continuation  of  the  longer 
margins  of  the  wound'  on  both  sides  of  the  area  to  be  covered, 
detachment  of  the  flaps  so  formed,  and  suture  along  the  middle  line. 
A  single  lateral  flap  may  suffice  in  some  cases  (Fig.  137). 

Letenneur's  operation  for  closure  of  a  quadrilateral  gap  comprises 
the  displacement  across  the  gap  of  a  flap  formed  by  the  incisions 
shown  in  Fig.  138.     The  margin  ef  is  sutured  to  the  margin  ad. 

Brnns  operation  (Fig.  139)  is  useful  in  cheiloplasty.  The  two  quad- 
rilateral flaps  are  swung  downward  (or  upward  in  case  of  the  lower 


J\ 


** 


if 

FIG.  138. — Letenneur's  operation. 


FIG.  139. — Brun's  operation. 


lip)  across  the  denuded  area,  and  their  free  margins  (r/and  h  i)  sutured 
in  the  middle  line. 

A  similar  method  may  be  employed  for  the  closure  of  large  ellip= 
tical  defects. 

Here  two  curved  flaps,  shaped  as  shown  in  the  figure,  are  freed  and 
displaced  upward  so  as  to  close  the  raw  surface.  In  the  method 
known  as  Weber's  operation  (also  shown  in  Fig.  140),  the  flaps  acd  and 
bef  are  formed,  the  point  c  carried  up  to  b,  and  the  margin  ab  sutured 


^~*;J 


„--''^v'^~*£ 


Fig.  140. — Operation  for  the  closure  of  elliptical  defects. 


^f 


to  a  c.     The  flap  b  ef  is  used  to  close  the  gap  left  by  the  displacement 
upward  of  the  flap  aed. 

3.  The  method  of  flap-formation  by  derivation  of  a  flap  from 
neighboring  tissue  by  twisting  of  its  pedicle  is  illustrated  by  those 
methods  of  rhinoplasty  by  which  a  flap  is  taken  from  the  cheeks  or 
forehead  {Indian  method). 

4.  The  fourth  method,  or  derivation  of  the  flap  from  distant  parts 
and  temporary  approximation  until  the  flap  has  healed  in  place,  may 
be  illustrated  by  the  Italian  method  of  rhinoplasty  (Fig.  141)  (see 
page  403),  in  which  the  new  nose  is  made  from  a  flap  taken  from  the 
arm. 


PLASTIC  SURGERY. 


399 


FIG.  141. — Italian  method  of  rhinoplasty 
from  the  arm,  which  is  immovably  secured 
to  the  head  until  union  of  the  flap  has  taken 
place  (Linhart). 


For  the  lining  of  cavities  ordinarily  lined  with  mucous  membrane, 
it  may  be  necessary  to  employ  the 
reversed  flap — i.  e.,  with  the  skin 
inward  and  the  raw  surface  out- 
ward. The  external  skin-surface 
may  be  then  supplied  by  swinging 
in  another  flap  to  cover  the  raw 
external  surface  of  the  former — the 
double  or  superposed  flap. 

Deformities  after  Burns. — 
Operations  for  the  relief  of  scar- 
contraction  after  burns  involving 
the  neck,  face,  and  upper  extremity 
are  not  infrequently  required,  and 
are  often  difficult  of  performance 
and  not  over-satisfactory  in  results. 
Especially  trying  are  burns  which 
draw  down  the  lower  lip,  resulting 
in  inability  to  close  the  mouth  and 
in  hideous  deformity.  Cicatricial 
bands  of  great  breadth  or  strength 
may  form  after  burns  of  the  axilla, 
and  prevent  raising  the  arm  from 
the  side.  Burns  on  the  flexor  sur- 
face of  the  fingers  may  total ly  dis- 
able a  hand  by  reason  of  cicatricial  contraction.  Simple  division  of 
these  cicatricial  bands,  or  even  their  excision,  leaving  the  resulting  raw 
surface  to  granulate,  is  unsatisfactory,  as  subsequent  recontraction  takes 
place,  reproducing  the  deformity.  The  best  results  have  been  attained 
by  the  swinging  in  of  ample  skin-flaps  to  cover  the  raw  surface  left  by 
excision  of  the  cicatrices.  The  areas  left  by  raising  the  flaps  may  be 
closed  by  subsidiary  plastics  or  by  skin-grafting. 

The  procedure  known  as  Croft's  operation  is  recommended  by 
Treves  as  being  one  of  the  most  satisfactoiy  methods  for  the  prevention 
of  recontraction  of  these  scars.  It  is  performed  in  two  stages.  The 
first  stage  consists  in  raising  a  strap  of  skin  from  the  integument  in  the 
neighborhood  of  the  scar,  and  after  suturing  the  edges  of  the  skin 
under  the  strap,  which  is  left  attached  at  both  ends,  a  piece  of  rubber 
tissue  is  placed  beneath  the  strap  to  prevent  its  healing  down  into 
place.  After  two  or  three  weeks,  during  which  time,  by  frequent  and 
careful  dressings,  the  strap,  especially  at  the  ends,  has  been  prevented 
from  healing  down,  the  under  surface  will  be  covered  with  healthy 
granulations.  The  second  step  of  the  operation,  which  consists  in 
dividing  the  cicatricial  band  until  healthy  tissues  are  exposed,  then 
severing  the  distal  end  of  the  strap,  swinging  it  over  the  raw  surface  left 
by  dividing  the  cicatrix,  and  suturing  it  in  place,  may  now  be  performed. 
The  shape  of  the  wound  and  of  the  transplant  must  be  fitted  as  far  as 
circumstances  allow,  and  the  edges  and  under  surface  of  the  free  end 
of  the  transplant  trimmed  and  cleaned  up  so  as  to  favor  primary  union. 
The  flap,  which  has  become  narrow  and  rounded,  will  flatten  and  stretch 
as  it  heals  in  place. 


400 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


Rhinoplasty. — The  term  rhinoplasty  is  properly  applied  to  restora- 
tion of  part  or  the  whole  of  the  structures  of  the  nose  which  have  been 


Fig. 


142. — Rhinoplasty  :  a,   lateral  flap 
von  Langenbeck's  method. 


Fig.   143, 


-Denonvillier's  method  of  rhino- 
plasty. 


destroyed  by  disease  or  injury.  Simple  integumental  defects,  such  as  are 
left  after  operations  for  epithelioma,  may  be  closed  by  granulation  or  skin- 
grafting,  and  do  not  require  plastic  operations  for  their  repair.  Rhinoplasty 
may  be  simple  of  performance  and  satisfactory  in  result,  or  difficult  and 
unsatisfactory,  according  to  the  amount  of  structures  which  give  sup- 
port and  prominence  to  the  nose — i.  e.,  the  septum  and  nasal  bones — 
which  have  been  destroyed. 

A  defect  of  the  ala  involving  the  lower  portion  or  the  whole  of  the 
ala  may  be  closed  by  lifting  a  flap  with  a  pedicle  from  the  cheek  close 
to  the  nose  and  swinging  it  inward  so  as  to  close  the  gap.  This  flap 
must  be  long  enough  for  the  lower  end  to  be  turned  in,  giving  a  lining 
of  skin  to  the  new  ala,  and  preventing  cicatricial  contraction  (Fig.  142,  a). 
Von  Langenbeck's  method  consisted  in  taking  the  flap  of  skin  from 

the  opposite  side  of  the  nose, 
with  the  pedicle  near  the  root 
of  the  nose,  and  swinging  it 
across  so  as  to  cover  the  defect. 
The  method  of  Dcnonvillicr 
consisted  in  employing  a  trian- 
gular flap  taken  from  the  same 
side  of  the  nose,  having  its  ped- 
icle at  the  center  of  the  lobe  of 
the  nose.  The  triangular  flap 
marked  out  by  the  incisions  as 
shown  in  Fig.  143  is  dissected 
up  clean  from  the  bone  and 
cartilage,  and  rotated  downward 
around  its  pedicle  till  the  gap  is 
filled.  The  defect  left  above  it 
It  has  the  advantage  of  furnish- 
ing a  border  that  is  already  at  least  partially  lined  with  epidermis. 


FlG.  144. — Formation  of  one  nostril  from  the  skin 
of  the  other  (after  Langenbeck). 

is  closed  by  granulation  or  grafting. 


PLASTIC  SURGERY. 


4OI 


Other  methods  have  been  described  by  which  an  ala  is  restored  by 
taking  a  flap  from  the  septum  and  attaching  it  to  the  margin  of  the  alar 
defect  with  its  mucous  surface  out.  This  operation  was  first  described 
by  Michon.  It  would  seem  to  possess  the  two  disadvantages  of  placing 
mucous  membrane  instead  of  skin  on  the  outer  surface  of  the  nose,  and 
of  providing  no  epidermoid  lining  for  the  new  ala. 

A  defect  of  the  columna  may  be  restored  by  taking  a  vertical 
flap  from  the  middle  of  the  lip,  having  its  pedicle  above,  twisting 
the  pedicle  so  as  to  bring  its  cutaneous  surface  downward,  and  sutur- 
ing the  raw  surface  to  the  carefully  cleaned  lower  margin  of  the  por- 
tion of  the  septum.  In  order  to  avoid  the  deformity  due  to  the  twist- 
ing of  the  pedicle,  Despres  took  the  flap  obliquely  from  the  upper 
lip,  so  that  it  had  to  be  twisted  only  half  so  far.  Sedillot  devised  the 
procedure  of  taking  the  flap  the  whole  thickness  of  the  lip,  taking 
the  skin  off  the  outer  surface,  and  turning  it  directly  upward,  so  that 
the  lower  border  of  the  new  columna  was  covered  with  mucous  mem- 
brane instead  of  skin.  It  is  stated  that  in  time  the  mucous  mem- 
brane loses  its  red  color  and  assumes  the  appearance  of  ordinary  skin. 

In  loss  of  the  entire  septum  and  nasal  bones,  resulting  in  the 
most  extreme  variety  of  sunken  nose,  Dieffenbach  and  Malgaigne 
divided  the  nose  into  three  portions  by  two  vertical  incisions  carried 
from  within,  clear  out  through  the  skin  close  to  the  septum,  and  two 
lateral  incisions  in  the  chinks  parallel  and  close  to  the  sides  of  the 
nose  and  surrounding  the  ala.  The  cheeks  were  dissected  up  through 
three  lateral  incisions,  the  upper  lip  freed  from  the  upper  jaw,  and  the 
lateral  nasal  flaps  completely  dissected  up.  The  columna  was  length- 
ened by  lateral  incisions,  and  the  center  and  sides  of  the  nose  passed 
into  place  and  fixed  by  harelip-pins  passed  transversely  from  side  to 
side  of  the  nose.  The  margins  of  the  wound  were  sutured  to  the 
free  margins  of  the  incisions  in  the  cheeks,  which  were  also  pinched 
up  toward  the  nose  and  held  there  by  long  pins  passing  through  the 
inner  portion  of  the  cheeks  and  through  the  nose. 

Oilier  performed  for  this  deformity  an  osteoplastic  operation,  taking 
a  triangular  flap  with  its  apex  \\  centimeters  above  the  eyebrows,  and 
its  base  constituted  by  the  inner  portion  of  the  nose  and  the  cheeks,  the 
periosteum  being  raised  with  the  frontal  portion  of  the  flap.  The  right 
nasal  bone  was  chiselled  off,  displaced  downward,  and  used  for  a  cen- 
tral support.  The  left  nasal  bone  had  been  destroyed  by  disease.  The 
whole  flap  was  then  displaced  downward,  and  the  lower  part  laterally 
compressed  in  order  to  raise  the  bridge,  and  kept  up  by  bringing  in 
the  cheeks,  which  had  been  loosened  at  the  sides,  and  supporting  them 
with  pins. 

Verneuil  employed  a  method  consisting  of  the  superposition  of  flaps, 
in  order  to  raise  the  bridge  of  the  nose.  A  flap  was  cut  from  the 
median  line  of  the  forehead,  as  shown  in  Fig.  145.  A  cut  along  the 
center  of  the  bridge  of  the  nose,  and  lateral  cuts  at  its  upper  and  lower 
ends,  allowed  the  reflection  of  skin-flaps  from  the  nose  and  cheeks. 
The  /flap  from  the  forehead  was  then  turned  directly  downward,  so 
that  its  skin-surface  lined  the  nasal  fossa,  and  the  lateral  flaps  drawn 
in  and  sutured  over  it  in  the  middle  line. 

Indian  Method. — A  model  of  a  nose  suited  to  the  case  is  made  of 

26 


402 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


wax,  plaster-of- Paris,  or  other  plastic  material,  and  a  pattern  of  paper 
or  cloth  made  of  its  surface.  The  outline  of  this  pattern  is  marked  on 
the  forehead  ;  its  apex  being  immediately  above  the  nose,  its  base  will 
reach  the  hair-line.  It  may  be  necessary  to  shave  the  head  for  an  inch 
from  the  hair-line  in  order  to  obtain  skin  for  the  columna.     The  frontal 


Fig.   145. — Rhinoplasty  for  sunken  nose  by  superposed  flaps  (Verneuil). 

flap  (Fig.  146)  should  be  one-third  longer  and  one-third  broader  than 
the  space  which  it  is  desired  to  fill.  In  order  to  avoid  encroaching  on 
the   hairy  scalp,  the  flap  may  be  taken  obliquely  from  the  forehead. 


Fig.  146. — Formation  of  flap  at  the  root  of  the   nose,  and  incision   for   Langenbeck's  model 

upon  the  forehead. 


The  oblique  flap  will  require  less  twisting  of  its  pedicle.  Twisting  of 
the  pedicle  is  favored  by  carrying  one  of  the  terminal  incisions  further 
downward  than  the  other.  The  edges  of  the  gap,  and  of  such  osseous 
and  cartilaginous  structures  as  remain,  which  should,  of  course,  be 
scrupulously  spared,  are  freshened,  and  the  flap  brought  down  and 
sutured  into  place,  being  supported,  if  necessary,  by  pins  and  by  the 
insertion  of  tubes  and  plugs  in  the  nostrils.  After  the  flap  has  healed 
in  place  the  pedicle  may  be  divided  and  suitably  trimmed.  The  results 
attained  by  this  operation  will  depend  in  large  measure  on  the  amount 


PLASTIC  SURGERY. 


403 


Fig.  147. — Rhinoplasty  :  Ollier's 
osteoplastic  method. 


of  septal  and  alar  cartilage  available  to  support  the  flap.    Otherwise  the 
result  will  be  a  mere  shapeless  curtain  hanging  across  the  gap. 

In  managing  the  pedicle  considerable  skill  is  required  to  avoid  such 
tight  twisting  as  may  result  in  gangrene  of  the  flap. 

Ollier's  Osteoplastic  Method. — In  a  case  in  which  lupus  had  destroyed 
the  tissues  of  the  end  of  the  nose  to  the  extent  shown  in  Fig.  147, 
Oilier  made  two  incisions  from  the  middle 
of  the  forehead,  2  inches  above  the  eye- 
brows, downward  to  the  cheeks,  just  out- 
side the  borders  of  the  alae.  This  flap  in- 
cluded the  periosteum  in  its  upper  position, 
and  on  arriving  at  the  nasal  bones  Oilier 
chiselled  one  of  them  from  its  attachments 
and  included  it  in  the  flap.  The  flap  was 
then  brought  directly  downward  in  front  of 
the  gap,  so  that  the  upper  end  of  the  freed 
nasal  bone  came  against  the  lower  end  of 
the  fixed  nasal  bone,  to  which  it  was  su- 
tured with  silver  wire,  thus  making  a  con- 
tinuous bony  bridge.  In  order  to  furnish  a 
septal  support,  the  cartilaginous  septum  was 
divided  from  before  backward  and  down- 
ward, and  this  portion  thus  separated  was 

brought  down  with  the  flap  till  it  rested  on  the  remains  of  the  lower 
part  of  the  original  septum. 

Italian  Method. — The  principle  of  this  method,  with  which  the  name 
of  Tagliacozzi  is  identified,  consists  in  supplying  material  for  the  new 
nose  from  the  arm.  It  is  suitable  in  certain  cases  in  which  the  Indian 
method  is  inapplicable — those,  for  instance,  where  the  forehead  is  cov- 
ered with  scar-tissue,  so  that  a  flap  cannot  be  taken  from  it.  It  is  also 
possible  to  provide  tissue  more  generously — an  important  advantage 
when  the  flap  is  taken  from  the  arm  rather  than  from  the  cheeks  or  fore- 
head. Tagliacozzi  cut  his  flap  from  the  front  of  the  upper  arm,  with  the 
apex  upward  and  the  broad  pedicle  2  inches  above  the  cubit  flexure. 
The  wound  was  sutured  under  the  raised  flap,  and  the  under  surface  of 
the  flap  carefully  prevented  from  healing  down  by  dressings  of  oiled  silk 
and  ointments  to  promote  suppuration.  After  the  under  surface  of  the 
flap  had  partly  cicatrized  the  arm  was  brought  up  against  the  nose  and 
held  by  a  helmet,  corset,  and  suitable  straps  (Fig.  141),  and  the  apex 
and  sides  of  the  flap  sutured  in  place  in  the  freshened  gap.  After  the 
flap  had  healed  into  its  new  bed  the  pedicle  was  divided  and  the  col- 
umna,  alae,  etc.  fashioned  from  its  lower  border. 

Later  operators  have  modified  these  procedures  by  suturing  the  flap 
in  place  immediately  or  dissecting  it  up  without  waiting  for  granula- 
tion, and  by  taking  the  flap  from  the  forearm  instead  of  the  upper  arm. 

The  results  from  rhinoplasty  in  cases  in  which  the  alae  and  project- 
ing parts  of  the  septum  are  destroyed  are,  on  the  whole,  so  unsatisfac- 
tory that  the  alternative  of  wearing  an  artificial  nose,  which  can  now  be 
very  skilfully  made,  and  by  means  of  spectacle-bows  attached  to  the 
face  so  as  to  escape  detection  by  most  observers,  is  well  worth  careful 
consideration. 


CHAPTER    XIII. 

MINOR   SURGERY. 

It  is  the  province  of  a  treatise  on  Minor  Surgery  to  describe  the 
common  instruments  and  materials  of  surgery  and  their  uses,  the  mak- 
ing of  incisions,  the  arrest  of  hemorrhage,  the  closure  and  dressing  of 
wounds,  the  performance  of  the  simpler  operations,  the  application  of 
splints  and  bandages,  and  many  of  those  manipulations  which  are 
employed  in  the  care  of  a  great  variety  of  surgical  cases  and  in  differ- 
ent regions  of  the  body.  In  view  of  the  fact  that  many  of  these  sub- 
jects have  been  discussed  in  other  portions  of  the  work,  it  will  be 
sufficient  for  this  chapter  to  present  a  consideration  of  the  points  not 
elsewhere  touched  upon.  It  is  well  to  remind  the  reader  that  the  term 
minor  is  by  no  means  synonymous  with  unimportant,  and  that  a  correct 
knowledge  of  minor  surgery  is  absolutely  necessary  in  the  manage- 
ment of  even  a  major  operation  and  in  the  subsequent  care  of  the 
case. 

BANDAGES. 

Bandages  are  applied  to  retain  splints  or  dressings,  to  make  com- 
pression, to  afford  support,  or  to  correct  deformity.  They  are  com- 
posed of  various  materials  and  are  of  different  shapes  and  sizes. 
Among  the  materials  used  for  the  purpose  of  making  bandages  may 
be  mentioned  gauze,  flannel,  calico,  silk,  linen,  elastic  webbing,  india- 
rubber,  and  unbleached  muslin.  Whatever  substance  is  used  must 
be  strong  enough  to  permit  of  firm  application,  and  must  be  supple 
enough  to  allow  of  neat  adjustment  to  the  part.  Calico  is  a  very  poor 
material,  being  too  light  and  apt  to  tear  and  crease ;  linen  and  silk  are 
expensive.  Gauze  is  useful  in  many  cases  ;  it  is  light,  can  be  neatly 
adjusted,  is  thin,  porous,  soft,  and  makes  even  compression.  One  of 
its  chief  uses  is  to  retain  dressings  upon  a  wound,  and  when  employed 
for  this  purpose  it  may  be  used  dry  or  may  be  moistened  with  an 
antiseptic  solution.  A  wet  gauze  bandage  can  be  applied  with  great 
neatness,  but  must  be  put  on  more  loosely  than  a  dry  bandage,  because 
it  contracts  on  drying,  and,  if  firmly  applied  while  wet,  may  become 
injuriously  tight  when  dry.  The  rubber  bandage,  in  the  form  known 
as  Martin's  bandage,  is  used  in  the  treatment  of  swollen  joints,  vari- 
cose veins  of  the  leg,  ulcers  and  eczema  of  the  lower  extremity.  In 
these  conditions  it  is  applied  before  the  patient  arises  in  the  morn- 
ing, and  is  removed  after  he  has  got  into  bed  at  night.  After  it  has 
been  taken  off,  it  should  be  washed  with  soap  and  water,  dried  with  a 
towel,  and  hung  over  a  chair-back  until  morning.  The  rubber  bandage 
of  Esmarch  is  used  to  prevent  hemorrhage,  and  occasionally  to  treat 
aneurysm.  A  flannel  bandage  is  elastic  and  very  soft.  It  is  capable 
of  neat  and  comfortable  adjustment,  affords  equal  compression,  keeps 

404 


BANDAGES.  405 

the  part  warm,  and  absorbs  moisture.  It  is  used  particularly  in  the 
treatment  of  sprains,  rheumatic  or  gouty  joints,  and  varicose  veins  of 
the  leg.  It  is  employed  to  surround  a  part  which  is  to  be  covered  with 
a  plaster-of-Paris  dressing,  and  is  very  useful  as  a  material  for  T-band- 
ages  and  abdominal  binders.  Ordinarily,  bandages  are  made  of  un- 
bleached muslin  which  has  been  washed,  dried,  and  torn  into  strips, 
each  strip  being  seamless  and  clear  of  selvage.  But  one  strip  should 
be  employed  to  make  a  bandage,  because,  if  two  strips  are  sewed 
together,  a  seam  is  formed,  and  such  a  seam  will  crease  the  skin. 
Selvage  must  be  removed,  because  it,  too,  will  crease  the  skin. 

Bandages  vary  in  width  and  length.  The  following  dimensions  for 
different  regions  are  given  by  Wharton  and  Curtis  :  Bandages  for  the 
hands,  fingers  and  toes,  1  inch  wide  and  3  yards  long ;  for  the  extremi- 
ties in  children,  2  inches  wide  and  6  yards  long;  for  the  extremities  in 
adults,  2\  inches  wide  and  7  yards  long ;  head-bandages,  2  inches  wide 
and  6  yards  long ;  thigh-  and  groin-bandages,  3  inches  wide  and  9 
yards  long;  trunk-bandages,  4  inches  wide  and   10  yards  long. 

To  make  a  bandage  the  material  can  be  rolled  into  a  cylindrical 
form  by  the  hand  or  by  a  machine.  Material  so  rolled  constitutes  a 
roller  bandage.  In  order  to  roll  a  bandage  by  the  hand,  one  end  of 
the  material  is  folded  to  the  extent  of  6  inches.  This  is  folded  upon 
itself  again  and  again  until  a  firm  center  or  core  is  constructed,  and 
over  this  stem  the  bandage  is  rolled  (Fig. 
148).  The  manipulation  of  rolling  is  carried 
out  as  follows :  The  extremities  of  the  stem 
are  grasped  between  the  thumb  and  fingers 
of  the  left  hand,  and  the  free  extremity  of 
the  bandage  between  the  thumb  and  index 
finger  of  the  right  hand.  The  bandage  is 
rolled  with  the  left  hand  and  kept  tight,  in 
order  to  secure  firmness,  with  the  right 
hand.  In  a  well-rolled  bandage  it  is  impos- 
sible to  push  out  the  core  with  the  finger. 
A  bandage-rolling  machine  is  very  largely 
used  in  hospitals.     A  bandage  rolled  from  0     _,  ... 

,         .  r.  1,     1         •       11  1     ,        11  Fig.  148. — Rolling  a  bandage  by 

one  end  only  is  called  a  single-headed  roller ;  hand. 

a  bandage  rolled  from  each  end  toward  the 

center   is   called    a    double-headed   roller.      The    single-headed  roller 

is    the    one    usually  employed.     Its   free  end    is  known  as  the  initial 

extremity ;  its  cylinder  is  called  the  body,  its  hidden  end  the  terminal 

extremity. 

Bandages  are  named  from  their  application  (circular,  spiral,  reversed, 
etc.),  from  their  uses  (suspensory  of  the  breast),  from  their  situation 
(crossed  of  the  angle  of  the  jaw),  from  their  shape  (figure-of-8),  and 
occasionally  after  the  person  who  devised  them  (Barton,  Gibson, 
Desault,  Velpeau). 

General  Rules  for  Bandaging. — The  surgeon  faces  the  patient, 
places  the  outer  surface  of  the  free  extremity  of  the  bandage  upon  the 
part,  and  retains  it  by  the  fingers  until  it  is  fixed  by  several  circular 
turns.  The  roller  is  held  between  the  thumb  and  fingers  of  the  right 
hand,  so  that  it  will  easily  unroll.     The  turns  of  the  bandage  must  be 


406  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

firm,  smooth,  even,  applied  so  as  to  make  equal  pressure,  and  never 
tight  enough  to  cause  discomfort.  In  taking  the  bandage  around  a 
joint,  the  part  should  first  be  placed  in  the  position  it  is  to  be  retained 
in  after  the  dressing  is  complete,  because  to  alter  the  position  after  the 
bandage  has  been  applied  may  lead  to  injurious  pressure.  When  the 
part  is  covered,  the  bandage  is  completed  by  two  circular  turns,  and 
the  terminal  end  is  fastened  by  a  safety-pin  to  the  turns  underneath. 
A  tight  bandage  causes  discomfort,  possibly  severe  suffering,  and 
may  even  lead  to  gangrene.  If  it  is  necessary  to  apply  a  firm  band- 
age above  the  periphery  of  the  limb,  the  peripheral  parts  should  be 
included  first,  in  order  to  prevent  swelling.  If  the  bandage  tends  to  slip, 
the  edges  or  crossing  should  be  stitched,  or  the  bandage  should  be 
covered  with  strips  of  adhesive  plaster.  In  order  to  remove  a  bandage, 
it  may  be  cut  with  bandage-shears,  or  the  pin  may  be  removed  from 
the  termination  and  the  material  unwound,  the  unrolled  part  being 
grasped  in  the  hand  and  transferred  from  one  hand  to  the  other. 

The  Elementary  Forms  of  Bandages. —  i.  Circular. — Circu- 
lar turns  are  made  round  and  round  a  part,  but  they  neither  ascend 
nor  descend,  and  each  turn  exactly  overlies  its  predecessor.  Such  a 
bandage  is  employed  to  retain  a  dressing  on  the  wrist,  neck,  or  fore- 
head, or  to  compress  the  veins  before  the  performance  of  venesection 
or  transfusion  of  saline  fluid. 

2.  Oblique. — Oblique  turns  are  carried  up  the  extremity  in  the 
manner  of  a  stripe  on  a  barber's  pole,  each  turn  having  between  it 
and  the  preceding  turn  an  uncovered  area  of  skin.  The  oblique  band- 
age is  used  to  lightly  retain  thick  and  loosely  applied  dressings  for 
burns  and  scalds. 

3.  Spiral. — In  this  method  the  bandage  is  carried  up  a  part,  each 
turn  overlying  one-third  of  the  preceding  turn.  This  bandage  is  often 
applied  to  the  chest  and  abdomen,  but  is  not  used  upon  the  extremi- 
ties, as  the  size  of  these  parts  becomes  progressively  greater  toward 
the  body,  so  that  a  spiral  bandage  would  be  tight  at  the  upper  border 
of  each  turn  and  loose  at  the  lower  border,  would  make  unequal  press- 
ure, and  would  tend  to  slip. 

4.  The  Spiral  Reversed. — The  reverse  corrects  the  inequality  exist- 
ing in  the  spiral,  and  by  means  of  reverses  a  conical  extremity  can  be 
evenly  bandaged.  A  reverse  is  made  in  the  following  manner  (Fig. 
149) :  If  the  initial  extremity  has  been  fixed  by  circular  turns,  the 
bandage  is  carried  up  the  limb  obliquely.  The  thumb  of  the  surgeon's 
left  hand  holds  the  unrolled  turn  to  keep  it  secure,  the  roller  is  pulled 
out  until  there  are  6  inches  of  free  bandage  between  the  thumb  and 
the  cylinder,  and  this  free  bandage  is  permitted  to  be  slack.  The 
supinated  hand  holding  the  roller  is  carried  transversely  under  the 
limb,  and  traction  is  made  to  cause  the  reverse  to  apply  itself  accu- 
rately to  the  surface.  All  the  reverses  should  be  in  line.  Reverses 
should  not  be  made  over  joints  or  bony  prominences. 

5.  The  Spica. — The  spica  is  used  to  cover  the  shoulder,  the  groin, 
the  thumb,  and  the  foot.  Each  turn  crosses  its  predecessor  so  as  to 
cover  two-thirds  of  it,  and  the  turns  take  the  form  of  the  Greek  letter 
lambda  (A),  and  when  applied  resemble  the  leaves  of  an  ear  of  corn. 

6.  The  Figure=of=8. — This  is  especially  useful  in  bandaging  joints, 


BANDAGES. 


407 


and  is  also  employed  to  bandage  the  neck  and  axillae  and  the  occiput 
and  jaw.     The  turns  resemble  in  shape  the  figure  8. 

7.  Recurrent. — The  recurrent  bandage  is  used  to  dress  the  head 
and  amputation-stumps.     The  part  is  covered  by  a  series  of  turns,  each 


Fig.  149. — Manner  of  making  the  reverse. 

one  of  which  recurs  to  its  point  of  origin,  and  the  recurrent  turns  are 
covered  by  spiral  or  spiral  reversed  turns. 

Forms  of  Compound   Bandages. —  1.  The  single  T=bandage 

consists  of  a  vertical  piece  which  is  stitched  or  pinned  to  a  horizontal 
piece.  It  is  used  for  the  perineum,  the  head,  the  anus,  and  the  scro- 
tum. To  apply  it  to  the  perineum,  the  horizontal  piece  is  fastened 
around  the  waist,  with  the  vertical  piece  behind.  The  ends  of  the 
horizontal  piece  are  pinned  together,  the  vertical  piece  pulled  between 
the  thighs,  the  end  torn  into  two  tails,  and  each  tail  taken  to  one  side 
of  the  genitalia  and  pinned  to  the  waist-piece. 

2.  The  double  T=bandage  is  used  to  hold  dressings  upon  the  back 
or  chest.  The  broad  piece  surrounds  the  chest  and  the  narrow  pieces 
pass  over  the  shoulders  as  suspenders. 

3.  The  many=tailed  bandage  is  made  of  muslin  or  flannel.  The 
ends    are    torn    almost  to    the   center  of  the 

material  into  as  many  tails  as  may  be  re- 
quired. Surgeons  frequently  use  the  many- 
tailed  bandage  to  retain  dressings  upon  the 
abdomen.  In  order  to  prepare  this  abdom- 
inal bandage,  a  piece  of  flannel  \\  yards 
long  and  2  feet  wide  is  torn  into  8  tails  at 
each  end,  the  center  is  applied  to  the 
patient's  back,  the  ends  are  brought  in 
front,  overlapped  successively,  and  pinned  in 
place. 

4.  The  four=tailed    bandage  (Fig.    150)  is 
used    chiefly   to    dress    fractures    of  the   jaw 

di_    1  j      j  ,_\  1  Fig.   i=;o. — Four-tailed   band- 

to    hold    dressings    upon    the    scalp    or  age  of  the  head. 

chin. 

5.  Mayor's  Handkerchief=dressings. — These  dressings  were  devised  by  Mayor 
of  Geneva.      He  showed  that  if  a  square  piece  of  muslin  is  taken,  different  methods  of  fold- 


408  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

ing  and  application  will  enable  one  to  dress  satisfactorily  various  regions  of  the  body.  A 
square  piece  folded  upon  itself  once  or  twice  constitutes  the  oblique  form  ;  bringing  the 
two  distinct  angles  together  forms  the  triangle.  If  the  point  of  the  triangle  be  taken  to  the 
base  and  the  material  be  folded  a  number  of  times,  the  cravat  is  formed.  Twisting  the 
cravat  forms  the  cord.  The  handkerchief-dressing  is  useful  to  cover  the  head,  the  groin,  or 
a  joint,  and  to  support  the  breast  or  the  testicles.  It  is  particularly  useful  in  emergencies 
and   in  military  practice. 

Slings. — A  sling  can  be  made  from  an  ordinary  roller  bandage,  by- 
means  of  which  the  extremity  is  hung  to  the  neck.  A  better  form  of 
sling  for  the  forearm  is  made  from  a  handkerchief,  and  is  called  the 
triangular  sling.  A  piece  of  muslin  a  yard  long  is  taken  and  folded 
into  a  triangle.  This  triangle  is  carried  under  the  limb,  with  its  apex 
projecting  behind  the  elbow,  the  portion  which  comes  from  under 
the  limb  being  carried  over  the  opposite  shoulder ;  the  other  portion 
is  lifted  and  carried  over  the  near  shoulder,  and  the  ends  are  fastened 
together  behind  the  neck.  The  apex  is  pulled  forward  from  behind 
the  elbow  and  pinned  to  the  anterior  portion.  This  sling  supports  the 
entire  forearm  and  hand. 

Fixed  Dressings. — Fixed  or  solid  dressings  are  used  in  the  treat- 
ment of  fractures,  injuries  and  diseases  of  joints,  after  operations  upon 
bones,  and  for  the  treatment  of  certain  deformities.  In  order  to  make 
a  fixed  dressing,  some  material  which  will  give  firmness  is  placed  in  the 
fabric  constituting  the  bandage,  either  before  the  application  of  the 
bandage  or  after  it  has  been  applied.  Dressings  may  be  rendered  solid 
by  the  use  of  plaster  of  Paris,  starch,  silicate  of  soda  or  of  potash,  glue 
and  zinc  oxid,  paraffin,  gum  and  chalk,  or  celluloid.  The  most  gen- 
erally useful  is  the  plaster-of-Paris  dressing,  which  differs  from  the 
other  materials  in  the  fact  that  it  does  not  contract  as  it  hardens,  but 
expands  a  little. 

Plaster  Bandage. — This  is  best  applied  after  Sayre's  method,  the 
dry  plaster  being  incorporated  into  gauze  or  crinoline  before  the 
bandage  is  applied.  The  best  calcined  plaster  of  Paris  is  necessary. 
The  extremity  is  bandaged  evenly  and  lightly  with  flannel,  and  cotton 
is  placed  over  the  bony  prominences ;  gauze  bandages,  each  one 
being  5  yards  long  and  3  inches  wide,  are  infiltrated  with  dry  plaster 
as  they  are  rolled  up.  They  are  usually  kept  ready  for  use,  wrapped 
in  waxed  paper  and  stored  in  a  glass  jar.  If  the  bandage  has  been 
prepared  for  some  time,  it  is  best  to  heat  it  in  an  oven  before  attempt- 
ing to  employ  it.  The  bandages  are  dropped  into  tepid  water  and 
should  be  entirely  submerged.  If  it  is  desired  to  have  them  set  quickly, 
the  water  should  contain  a  little  salt ;  if  they  are  to  set  slowly,  it  should 
contain  a  little  stale  beer.  The  bandage  is  ready  to  use  when  bubbles 
of  air  have  ceased  to  be  given  off  from  it.  It  is  then  removed  from 
the  water,  squeezed,  and  applied.  It  is  applied  from  the  periphery 
upward,  evenly,  firmly,  but  never  tightly.  Three  or  four  thicknesses 
are  usually  sufficient,  but  if  it  is  desirable  to  render  the  dressing  par- 
ticularly strong,  pieces  of  wood,  tin,  zinc,  or  pasteboard  may  be  placed 
between  the  folds  of  the  bandage  as  it  is  being  applied.  A  plaster 
bandage  becomes  firm  in  fifteen  or  twenty  minutes,  but  it  should  not 
be  trusted  to  bear  weight  for  several  hours.  After  it  is  dried,  it  is  a 
good  plan  to  varnish  it  in  order  to  prevent  chipping  (Bryant). 

Gigli  has  devised  a  useful  method  of  applying  the  plaster  bandage. 


BANDAGES. 


409 


After  putting  the  flannel  and  cotton  around  the  limb,  this  surgeon 
places  a  layer  of  moist  parchment  paper  over  the  flannel  upon  the 
front  of  the  limb,  and  upon  it  a  thick  cord  greased  with  vaselin  is  laid, 
in  the  direction  one  would  need  to  saw  to  open  the  plaster ;  over  this 
the  plaster  is  applied.  When  in  the  course  of  time  we  are  ready  to 
remove  the  plaster,  the  cord — ends  of  which  project  beyond  the  band- 
age— is  loosened,  and  one  end  is  tied  to  a  fine  steel  wire  which  has 
been  nicked  transversely  at  intervals  by  means  of  a  file.  The  wire  is 
drawn  through  the  cavity  which  was  previously  occupied  by  the  cord. 
Each  end  of  this  wire  is  wound  around  a  piece  of  wood  which  is  to 
serve  as  a  handle,  and  the  plaster  is  then  readily  sawed  through  from 
within  outward. 

It  is  occasionally  necessary  to  apply  what  is  known  as  the  inter- 
rupted plaster  dressing  (Fig.  151),  the  interruption  in  the  plaster 
enabling  the  surgeon  to  reach  a  wound  and  dress  it  readily  while 
the  part  is  perfectly  immobilized.     In  order  to  apply  such  a  dressing,  a 


FlG.  151. — Interrupted  plaster-of- Paris  dressing. 

piece  of  wood  or  iron  is  placed  underneath  the  extremity,  running 
above  and  below  the  level  of  the  point  which  is  to  be  left  open,  and 
fixed  thus  with  a  few  turns  of  the  plaster  bandage  at  its  extremities. 
A  piece  of  tin  or  iron  is  bent  into  a  large  loop,  the  ends  of  this  piece 


Fig.  152. —  Trap-door  dressin 


are  laid  upon  the  surface  and  caught  in  the  turns  of  the  plaster  bandage. 
It  may  be  necessary  to  use  one,  two,  or  three  of  these  brackets,  accord- 
ing to  the  degree  of  firmness  which  is  desired.  A  good  many  surgeons 
in  applying  an  uninterrupted  plaster  dressing  lay  upon  the  front  surface 
of  the  limb,  before  applying  the  plaster,  a  piece  of  zinc,  and  when  it 


41 0  IXTER NATIONAL    TEXT-BOOK  OF  SURGERY. 

becomes  necessary  to  remove  the  plaster,  this  zinc  protects  the  limb 
from  injury.  In  some  cases  a  plaster  bandage  is  applied,  is  cut  down 
the  front  while  soft,  and  is  subsequently  flanged  open.  Such  a  dress- 
ing can  be  removed  whenever  necessary,  and  yet  gives  excellent  sup- 
port. It  can  be  retained  firmly  in  place  by  adhesive  strips  and  tapes, 
by  applying  an  ordinary  bandage  outside  of  it,  or  by  putting  eyelet- 
holes  in  the  edges  and  lacing  it  up  like  a  shoe.  Instead  of  making  a 
bracketed  splint,  a  trap-door  may  be  cut  in  the  plaster  dressing  directly 
over  the  area  which  the  surgeon  afterward  desires  to  reach  (Fig.  152). 
The  methods  of  applying  the  plaster  jacket  and  the  jury-mast  will  be 
presented  in  the  articles  upon  the  Surgery  of  the  Spine.  A  plaster 
bandage  can  be  removed  by  splitting  it  with  a  knife  while  it  is  still 
moist,  by  sawing  it  when  it  is  dry  with  Hunter's  saw,  or  by  cutting  it 
with  one  of  the  various  forms  of  plaster-cutters.  It  is  best,  in  applying 
this  bandage  originally,  to  use  Gigli's  method,  which  renders  the  sub- 
sequent removal  a  most  simple  matter. 

Starch  Bandage.— The  starch  bandage  (known  also  as  Seutin's  bandage)  was  used 
extensively  before  the  invention  of  the  plaster  bandage.  The  starch  is  mixed  with  cold 
water  until  it  is  of  a  creamy  consistency,  and  boiling  water  is  added  until  the  mixture  is  muci- 
laginous. The  extremity  is  bandaged  with  flannel,  over  which  a  gauze  bandage  is  applied. 
This  bandage  must  be  shrunk  before  application,  as  otherwise  it  will  make  undue  con- 
traction as  it  dries.  The  starch  mixture  is  rubbed  into  the  gauze  bandage,  and  another 
bandage  is  applied  ;  more  starch  is  rubbed  in,  and  so  on  until  the  extremity  is  covered  with 
a  sufficient  thickness.  In  some  cases  pieces  of  pasteboard  are  added  to  give  additional 
solidity.      This  bandage  dries  in  about  thirty-six  hours. 

The  Silicate=of=SOda  Bandage. — This  material  is  usually  spoken  of  as  soluble  glass. 
Silicate  of  potassium  can  be  used  equally  well.  The  extremity  is  bandaged  with  flannel, 
and  over  this  are  applied  several  layers  of  a  gauze  bandage.  The  silicate  is  rubbed  in  with 
a  brush,  another  gauze  bandage  is  applied,  more  silicate  is  rubbed  in,  and  so  on  until  a 
sufficient  thickness  is  obtained.  It  requires  twenty-four  hours  to  dry.  In  order  to  remove 
it,  the  extremity  covered  with  the  bandage  should  be  placed  in  warm  water  and  the  dressing 
cut  with  scissors. 

Gum=and=chalk  Bandage. — This  material  is  prepared  by  making  it  into  a  paste  by 
the  addition  of  boiling  water.  It  is  applied  like  the  starch  bandage,  is  more  solid  than  is 
that  dressing,   and  becomes  hard  in  five  or  six  hours. 

Glue  Bandage. — This  was  devised  by  De  Morgan.  French  glue  is  soaked  in 
cold  water,  heated  in  a  glue-pot,  and  applied  like  the  starch  bandage.  The  addition  of 
\  part  of  methylated  spirit  greatly  accelerates  the  drying  process.  The  late  Dr.  Levis  was 
accustomed  to  mix  oxid  of  zinc  with   the  glue. 

Paraffin  Bandage  (Tait'S  Bandage). — Paraffin  is  a  material  which  is  impenetrable 
by  the  body-secretions.  It  melts  at  105°  to  1200  F.  The  bandage  is  passed  through  the 
melted  paraffin  as  it  is  being  applied.      This  bandage  becomes  solid  in  about  ten  minutes. 

The  Celluloid  Bandage. — This  is  strongly  commended  by  Landerer  and  Kirsch.1  It  is 
made  by  saturating  mull  bandages  in  a  solution  of  celluloid  in  acetone.  The  celluloid  is 
cut  into  small  pieces  ;  a  glass  jar  is  filled  one-quarter  full  of  these  pieces,  and  is  then  filled 
up  with  the  acetone  and  the  lid  put  on.  At  intervals  the  mixture  is  stirred  with  a  glass  rod. 
The  bandage  is  applied  over  a  plaster  cast  of  the  part,  which  is  bandaged  with  flannel. 
Over  this  a  mull  bandage  is  applied.  By  means  of  the  hand  gloved  with  leather,  the 
celluloid  gelatin  is  applied  to  the  mull,  another  mull  bandage  is  applied,  more  celluloid 
gelatin  is  applied,  and  so  on.  The  outer  layer  consists  of  celluloid.  From  4  to  10  layers  may 
be  necessary  according  to  the  requirements  of  the  case.  Within  one  and  one-half  hours  the 
dressing  is  firm  enough  to  be  fitted  upon  the  person,  and  in  four  hours  it  is  completely  dry. 
This  bandage  is  cheap,  is  light,  and  is  not  affected  by  the  body-secretions. 

Bandages  of  Special  Regions. — Spiral  Reversed  Bandage  of 
the  Upper  Extremity  (Fig.  153). — This  bandage  is  begun  by  making 
a  circular  turn  around  the  wrist  and  a  second  turn  to  hold  the  first. 
It  is  then  carried  obliquely  across  the  back  of  the  hand  to  near  the 

1  Centralbl.  f.  R~inderhei!k.,  1896,  Bd.  i.,  S.  307. 


BAND  A  GES. 


411 


extremity  of  the  fingers,  and  ascends  the  hand  to  the  root  of  the  thumb 
by  several  spiral  turns ;  the  wrist  is  covered  by  ascending  figure-of-8 
turns,  the  forearm  is  covered  by  spiral  reversed  turns,  the  elbow-joint 
by  figure-of-8  turns,  and  the  arm  by  a  series  of  spiral  reverses.  The 
bandage  is  terminated  by  two  circular  turns  which  are  pinned  to  each 
other. 


Fig.  153. — Spiral  reversed  bandage  of  the  upper  extremity. 


Spiral  Bandage  of  all  the  Fingers,  or  the  Gauntlet  (Fig.  1 54). — 
Two  circular  turns  are  made  around  the  wrist ;  the  bandage  is  carried 
obliquely  across  the  back  of  the  hand  to  the  root  of  the  thumb,  and 
is  taken  to  the  tip  of  the  thumb  by  spiral  turns.  The  thumb  is  covered 
in  by  ascending  spiral  turns,  and  the  bandage  is  returned  to  the  wrist. 
Each  finger  is  covered  in  the  same  manner,  and  the  bandage  is  termi- 
nated  by  two  circular  turns  about  the  wrist. 

Spiral  Bandage  of  the  Palm  or  Dorsum  of  the  Hand  ;  the  Demi= 
gauntlet  ( Fig.  1 55). — This  bandage  is  of  but  limited  utility.  It  must  not 
be  applied  tightly,  as  it  makes  considerable  pressure  at  the  roots  of  the 


Fig.  154. — Gauntlet  bandage. 


Fig.  155. — Demi-gauntlet  bandage. 


fingers,  although  it  leaves  the  fingers  free.  If  the  wish  is  to  cover  the 
palm,  the  bandage  is  begun  with  the  patient's  hand  supinated ;  if  the 
desire  is  to  cover  the  dorsum,  it  should  be  started  with  the  hand  pro- 
nated.     Two  circular  turns  are  made  around  the  wrist;  the  bandage  is 


412  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

caught  around  the  root  of  the  thumb  and  taken  back  to  the  point  of 
origin.  Each  finger  is  covered  in  the  same  manner,  and  the  bandage  is 
ended  by  a  series  of  ascending  figure-of-8  turns  about  hand  and  wrist. 
Spica  Bandage  of  the  Thumb  (Fig.  156). — This  is  begun  at  the 
wrist,  and  is  taken  to  the  end  of  the  thumb  in  the  same  manner  as  is  the 


Fig.  156. — Spica  bandage  of  the  thumb. 

gauntlet  bandage.  A  series  of  ascending  spica  turns  are  made  between 
the  thumb  and  wrist,  each  turn  overlying  two-thirds  of  the  previous 
turn.  The  bandage  is  terminated  by  two  circular  turns  at  the  wrist. 
Selva's  thumb=bandage  (Fig.  157)  covers  the  entire  thumb.  The 
terminal  end  of  the  bandage  is  placed  on  the  outside  of  the  second 
phalanx  of  the  thumb,  near  to  the  base  of  the  phalanx.     The  bandage 


Fig.  157. — Selva's  thumb-bandage. 

is  then  carried  over  the  palmar  side  of  the  pulp  of  the  last  phalanx  to 
the  inner  side  of  the  second  phalanx,  this  turn  being  held  temporarily 
in  place  by  the  surgeon's  left  thumb  and  index  finger.  The  roller  is 
taken  back  as  a  recurrent  to  its  place  of  origin,  is  made  to  overlap  the 
preceding  turn,  and  is  placed  as  much  as  possible  on  the  dorsum.  It 
is  then  carried  over  the  terminal  phalanx,  and  is  turned  around  the  tip, 
the  loop  crossing  over  the  center  of  the  nail.  Ascending  spica  turns 
are  now  made  over  the  dorsum  of  the  hand  and  over  the  palm,  return- 
ing to  the  phalanx. 

Spiral  Reversed  Bandage  of  the  Lower  Extremity  (Fig.  158). — Two 
circular  turns  are  made  just  above  the  malleoli,  and  an  oblique  turn 
is  carried  across  the  dorsum  of  the  foot  and  the  metatarsophalangeal 
articulation.  A  circular  turn  is  now  made,  and  the  foot  is  covered  with 
ascending  spiral  reversed  turns.  The  bandage  returns  to  the  ankle  as 
a  figure-of-8,  ascends  the  leg  by  spiral  reversed  turns,  covers  the  knee 


BANDAGES. 


413 


by  a  figure-of-8,  ascends  the  thigh  by  spiral  reversed  turns,  and  termi- 
nates by  two  circular  turns. 

Bandage  of  the  Foot,  Covering  the  Heel  {American  Bandage  of  the 
Foot)  (Fig.  159). — The  bandage  is  begun  in  the  same  manner  as  a  spiral 
reversed  bandage  of  the  lower  extremity.  After  the  foot  is  well  cov- 
ered by  ascending  spiral  reversed  turns,  the  bandage  is  carried  around 
the  point  of  the  heel  and  is  returned  to  the  instep.  From  this  point  it 
is  carried   under  the  sole  of  the  foot,  around  the  back  of  the  ankle- 


FlG.  158.— Spiral  r 


d  bandage  of  the  lower  extremity. 


joint,  down  the  side  of  the  heel,  under  the  heel  up  to  the  instep,  around 
the  ankle  in  the  opposite  direction,  down  the  opposite  side  of  the  heel, 
under  the  heel  and  up  to  the  instep.  The  roller  is  carried  to  above  the 
malleoli,  and  the  bandage  is  terminated  by  two  circular  turns. 

Bandage  of  the  Foot,  not  Covering  the  Heel  {French  Method). — 


Fig.  159. — Bandage  of  the  foot,  covering  the 
heel. 


Fig.  160. — Spica  bandage  of  the  foot. 


This  has  already  been  set  forth  in  the  description  of  the  spiral  reversed 
bandage  of  the  lower  extremity. 

Spiral  Bandage  of  the  Foot,  Covering  the  Heel  {RibbaiPs  Bandage, 
or  the  Spica  of  the  Foot,  Fig.  160). — A  bandage  identical  with  the  ascend- 
ing spiral  reverse  of  the  lower  extremity  is  applied  until  the  metatarsus 
is  well  covered.  The  bandage  is  carried  parallel  with  the  margin  of  the 
foot,  back  along  the  inner  margin  or  the  outer  margin  (according  as  to 
whether  we  are  dealing  with  the  left  foot  or  the  right),  around  the  pos- 


4H 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


terior  portion  of  the  heel,  forward  along  the  opposite  edge  of  the  foot; 
cross  the  original  turn  at  the  median  line  of  the  dorsum  of  the  foot, 
where  a  number  of  these  turns  are  made  and  caused  to  ascend,  each 
turn  covering  two-thirds  or  three-fourths  of  the  previous  turn.  The 
bandage  is  terminated  by  circular  turns  about  the  ankle. 

Crossed  Bandage  of  Both  Eyes,  or  Figure=of=8  of  Both  Eyes  (Fig. 
161). — A  circular  turn  is  made  around  the  forehead  from  right  to  left. 
The  second  turn  is  applied  to  hold  the  first,  and  then  the  bandage  is 
carried  downward  over  the  left  eye,  under  the  left  ear,  around  the  back 
of  the  neck,  upward  under  the  right  ear,  and  over  the  right  eye.  These 
turns  are  repeated  so  as  to  ascend,  and  the  bandage  is  terminated  by  a 
circular  of  the  forehead. 

Borsch's  Eye=bandage  (Fig.  162). — A  narrow  bandage  is  laid  along 
the  head  so  that  one  end  will  hang  in  front  of  the  sound  eye  and  the 


Fig.  161. — Crossed  bandage  of  both  eyes. 


Fig.  162. — Borsch's  eye-bandage. 


other  down  to  the  back  of  the  neck.  A  circular  bandage  is  applied 
over  this  strip  so  as  to  cover  both  eyes ;  the  posterior  portion  of  the 
narrow  strip  is  pinned  to  the  circular  turn  at  the  occiput,  while  the 
lower  end  of  the  anterior  portion  of  the  narrow  strip  is  lifted  and 
pinned  to  the  same  strip  further  back.  The  lifting  of  the  narrow 
strip  raises  the  bandage  away  from  the  sound  eye. 

Barton's  Bandage  {Figure-of-8  of  the  Jazv  and  Occiput,  Fig.  163). — 
The  initial  extremity  of  the  bandage  is  placed  below  the  inion,  and  a 
turn  is  carried  over  the  right  parietal  bone,  across  the  vertex,  down  the 
left  side  in  front  of  the  ear,  under  the  chin,  up  the  right  side  in  front 
of  the  ear,  across  the  vertex,  and  over  the  parietal  bone  to  the  point  of 
origin.  A  turn  is  now  taken  forward  along  the  right  side  to  the  jaw 
and  backward  along  the  left  side  of  the  jaw  to  the  nape  of  the  neck. 
These  figure-of-8  turns  are  repeated  as  often  as  may  be  necessary  for 
firmness,  and  the  bandage  is  finished  by  circular  turns  around  the 
forehead.  After  Barton's  bandage  has  been  applied,  the  ears  lie  in 
uncovered  triangles. 

Gibson's  Bandage  (Fig.  164). — Three  vertical  turns  are  made  around 
the  head  and  jaw,  in  front  of  the  ears.     A  half-turn  is  taken  in  the 


BANDAGES. 


415 


bandage  just  above  the  level  of  the  ears,  and  the  turns  are  carried 
horizontally  around  the  forehead  and  occiput  three  times.  The  band- 
age is  then  dropped  to  the  nape  of  the  neck,  and  three  horizontal  turns 
are  taken  around  the  neck  and  jaw.     The  bandage  is  terminated  by 


Fig.  163. — Barton's  bandage. 


Fig.  164. — Gibson's  bandage. 


carrying  a  half-turn  upward  and  forward  from  the  nape  of  the  neck  and 

along  the  vertex  to  the  forehead.     It  is  then  pinned  at  its  origin,  and 

also  over  the  forehead.    It  is  well  to  pin  or  stitch  the  points  of  crossing. 

Crossed  Bandage  of  the  Angle  of  the  Jaw  [Oblique  Bandage  of  the 


Fig.   165. — Crossed  bandage  of  the 
angle  of  the  jaw. 


FIG.  166. — Spica  bandage  of  the  groin. 


Jaw,  Fig.  165). — A  circular  turn  is  made  around  the  forehead  toward 
the  affected  side,  and  a  second  turn  is  applied  to  hold  the  first.     The 


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INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


bandage  is  then  carried  to  the  back  of  the  neck,  forward  under  the  ear 
of  the  sound  side  to  the  under  surface  of  the  jaw,  and  is  then  taken 
upward  in  front  of  the  ear  of  the  injured  side.  A  series  of  turns  are 
now  made  in  front  of  the  ear  of  the  injured  side  and  back  of  the  ear  of 
the  sound  side.  The  turns  which  are  in  front  of  the  ear  progressively 
advance,  while  those  which  are  back  of  the  ear  remain  on  the  same 
level.  In  order  to  terminate  the  bandage,  it  is  carried  back  under  the 
ear  of  the  injured  side  to  the  nape  of  the  neck,  and  then  two  circular 
turns  are  taken  around  the  forehead. 

Spica  of  the  Groin  {Figure-of-8  of  the  Tliigh  and  Pelvis,  Fig.  166). — 
For  the  double  spica  two  circular  turns  are  made  from  right  to  left 
around  the  waist.  The  bandage  is  carried  downward  over  the  front  of 
the  right  groin,  around  the  back  of  the  thigh,  upward  over  the  front 
of  the  right  groin  and  around  the  waist,  downward  over  the  front  of 
the  left  groin,  around  the  back  of  the  thigh,  up  over  the  front  of  the 
left  groin,  and  around  the  waist.  A  map  of  the  bandage  is  thus  laid 
out,  and  the  following  turns  ascend,  each  one  overlying  one-third  of  its 
predecessor,  the  bandage  being  completed  by  a  circular  turn  around  the 
waist.  It  is  needless  to  describe  the  single  spica,  as  it  is  obvious  that 
it  is  caught  back  of  but  one  thigh. 

Spica  of  the  Shoulder  (Fig.  167). — A  circular  turn  is  made  around 
the  upper  arm,  followed  by  several  spiral  reversed  turns.  From  behind 
forward  the  bandage  is  carried  over  the  shoulder,  across  the  front  of 


Fig.  167. 


bandage  of  the  shoulder. 


Fig.  168. — Figure-of-8  bandage  of  the  neck 
and  axilla. 


the  chest  into  the  opposite  armpit,  and  is  returned  across  the  back  at 
the  posterior  aspect  of  the  shoulder.  A  series  of  ascending  turns  are 
thus  applied. 

Fiffure-of-8  bandages  of  the  neck  and  axilla,  and  of  the  chest,  and 
of  the  breast  are  shown  in  Figs.  168- 170. 

Velpeau's  Bandage  (Fig.  171). — The  hand  of  the  injured  side  is 
placed  upon  the  shoulder  of  the  sound  side,  and  the  elbow  is  laid 
against  the  chest.     It  is  well  to  interpose  some  lint  or  cotton  between 


BANDAGES. 


417 


the  elbow  and  the  chest.  The  bandage  is  begun  at  the  axilla  of  the 
sound  side  posteriorly.  It  is  Carried  over  the  back,  the  shoulder  of  the 
injured  side,  down  the  front  of  the  arm,  under  the  arm  just  above  the 


Fig.  169. — Posterior  figure-of-8  bandage  of  the  chest. 

elbow,  returning  to  its  point  of  origin.  The  second  turn  is  applied 
exactly  over  this  one  to  hold  it  in  place,  but  on  reaching  the  axilla  with 
this  second  turn  the  bandage  is  taken   directly  across  the  back  and 


Fig.  170. — Suspensory  and  compressor  bandage  of  the  breast. 

around  the  chest,  including  the  arm.  Each  alternate  turn  is  now  car- 
ried over  the  injured  clavicle,  and  each  alternate  turn  is  made  to  encircle 
the  arm  and  body,  the  clavicular  turns  passing  progressively  forward, 
the  arm-  and  body-turns  regularly  ascending. 


4i8 


INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 


Desault's  Apparatus. — This  apparatus  consists  of  three  rollers  a  pad,  and  a  sling. 
The  pad,  which  is  wedge  shaped,  is  placed  in  the  axilla  of  the  injured  side,  it-  base  being 
upward.      The  first  roller  is  a  .spiral  of  the  chest   (  Fig.  172),  which  holds  the  pad  in  plai  e. 


FIG.  171. — Velpeau's  bandage. 

The  second  roller  binds  the  arm  to  the  side  over  the  pad  (Fig.  173),  and,  by  throwing  the 
shoulder  out,  corrects  the  inward  deformity  of  the  fractured  clavicle.     The  third  roller  is 


Fig.  172. — Desault's  bandage,  first  roller. 


started  under  the  axilla  of  the  sound  side  anteriorly.      It  crosses  the  chest  to  the  shoulder 
of  the  injured  side,  is  carried  down  back  of  the  arm,  around  the  elbow,  and  upward  on  the 


BAXDAGES. 


419 


front  of  the  chest  to  the  point  of  origin.      It  is  now  carried  through  the  axilla  to  the  back, 
upward  across  the  back  and  shoulder  of  the  injured  side,  down  the  front  of  the  arm,  around 


Fig.  173. — Desault's  bandage,  second  roller. 

the  elbow,  and  across  the  back  to  the  axilla  of  the  sound  side.  When  these  turns  have 
been  applied,  it  will  be  observed  that  they  leave  uncovered  two  triangular  spaces  front  and 
back,  which  are  spoken  of  as  the  anterior  and  the  posterior  triangles.      The  third  roller  of 


Fir,.  174. — Desault's  bandage  completed. 


Desault  corrects  the  downward  and  forward  deformity  of  the  fracture  of  the  clavicle.     After 
the  third  roller  has  been  applied  the  hand  is  hung  in  a  sling  (Fig.  174). 


420 


INTERNATIONAL    TEXT- BOOK   OF  SURGERY. 


FIG.  175. — Recurrent  bandage  of  the 
head. 


Recurrent  Bandage  of  the  Head  (Fig.  175). — Two  circular  turns 
are  carried  around  the  forehead  and  head.     When  the  middle  of  the 

forehead  is  reached,  a  half-turn  is 
made  and  the  bandage  is  carried  to 
the  occiput.  Another  half-turn  is 
made,  and  the  bandage  is  carried  for- 
ward to  the  forehead,  so  as  to  cover  a 
portion  of  the  preceding  turn.  These 
recurrent  turns  are  applied  until  the 
head  is  covered,  and  while  they  are 
being  applied,  an  assistant  catches 
them  at  the  forehead  and  occiput. 
When  the  head  is  covered,  the  band- 
age is  terminated  by  two  circular 
turns  around  the  forehead  and  occi- 
put, applied  firmly  and  holding  the 
ends  of  the  recurrent  turns.  It  is 
well  to  carry  a  turn  or  two  around 
the  head  and  chin,  and  to  pin  these 
vertical  turns  to  the  horizontal  fore- 
head turns. 

Recurrent  Bandage  of  a  Stump. 
— Two  light  circular  turns  are  taken  around  the  root  of  the  stump. 
The  stump  is  covered  by  recurrent  turns  exactly  as  was  the  head. 
A  light  circular  turn  is  made  around  the  root  of  the  stump,  an 
oblique  turn  is  carried  to  the  top  of  the  stump,  and  an  ascending 
spiral  reverse  bandage  is  applied,  which  is  terminated  by  two  circular 
turns. 

Splints. — A  splint  is  a  firm  material  applied  to  an  extremity  in 
order  to  secure  immobilization.  Splints  are  of  various  shapes  and 
sizes,  suitable  for  different  injuries  in  particular  regions.  They  may  be 
made  of  wood,  plaster  of  Paris,  felt,  leather,  binders'  board,  zinc,  tin, 
copper,  etc.  Before  a  splint  is  applied,  it  must  be  well  padded,  espe- 
cially at  the  points  which  will  come  in  contact  with  bony  prominences. 
Pads  are  made  of  cotton,  oakum,  or  wool.  They  reach  beyond  the 
ends  and  over  the  sides  of  the  splint,  and  are  held  in  place  by  tapes  or 
bandages.  A  splint  should  be  applied  firmly,  but  never  tightly.  It  is 
a  wise  precaution  in  applying  a  splint  to  the  forearm  to  leave  the  ends 
of  the  fingers  in  view,  and  in  applying  a  splint  to  the  leg  to  leave  the 
toes  in  view.  The  condition  of  the  circulation  in  the  digits  is  a  gauge 
of  the  state  of  the  circulation  in  the  limb.  A  splint  is  held  in  place  by 
bandages,  and  when  it  is  desired  to  remove  the  splint,  the  bandage  is 
first  cut  loose  with  shears.  The  use  of  special  forms  of  splints  is  con- 
sidered in  various  sections  of  this  work. 

Adhesive  Plaster. — This  is  a  very  useful  material,  but  should 
never  be  directly  applied  to  a  wounded  surface.  It  is  never  aseptic, 
and  will  of  necessity  infect  any  wound  with  which  it  is  brought  in  con- 
tact. Adhesive  plaster  is  used  to  retain  dressings,  to  keep  bandages 
from  slipping,  to  make  compression,  to  immobilize  a  part,  to  make 
extension  upon  an  extremity,  or  to  protect  a  portion  of  the  surface  of 
the  body.     Resin-plaster   has   its   sticky  surface   covered  with  tissue- 


BANDAGES. 


42I 


paper.  When  resin  plaster  is  to  be  used,  the  tissue  paper  is  removed 
and  the  plaster  cut  lengthwise  into  strips.  The  plaster  is  placed  for  a 
moment  with  the  unspread  side  against  a  jug  of  hot  water,  and  as  soon 
as  the  spread  side  becomes  sticky,  it  is  ready  for  use.  The  part  to  which 
the  plaster  is  to  be  applied,  if  hairy,  should  be  shaved. 

Rubber  plaster  will  adhere  most  tenaciously  without  any  previous 
heating,  but  it  is  more  irritant  to  the  skin  than  resin  plaster. 

Soap  plaster  does  not  adhere  with  sufficient  tenacity  to  permit  of 
its  use  as  a  material  to  make  firm  compression  or  extension.  Its  chief 
use  is  to  cover  and  protect  a  part — for  instance,  an  incipient  bed-sore 
or  a  bony  prominence — before  splints  are  applied. 

Strapping  of  the  Testicle  (Fig.  176).— This  procedure  is  carried  out 


Fig.  176. — Strapping  of  the  testicle  (Smith). 


in  the  subsiding  stage  of  an  epididymitis  or  orchitis,  and  is  occasion- 
ally employed  after  tapping  a  hydrocele.  Strips  of  resin  plaster  are 
employed,  each  strip  being  \  inch 
wide  and  10  or  12  inches  long. 
After  the  scrotum  has  been  washed, 
shaved,  and  dried,  the  surgeon 
constricts  it  at  the  upper  end  of 
the  testicle,  passes  a  circular  strip 
of  plaster  around  the  scrotum 
above  the  testicle,  and  then  applies 
a  series  of  long  recurrent  strips, 
covering  them  with  transverse 
strips. 

Strapping  of  the  Breast  (Fig. 
177). — In  chronic  inflammations  of 
the  breast,  it  is  sometimes  useful  to 
strap  with  resin  plaster.  The  ma- 
terial is  cut  in  strips  2  inches  wide 
and   of   sufficient    length    to   pass 

under  the  breast,  over  the  far  shoulder,  and  across  the  back  to  the 
point  of  origin.  The  first  strip  is  applied  at  the  lower  portion  of  the 
breast.  The  second  strip  is  on  a  higher  level  and  overlies  one-third  of 
the  previous  strip.     In  this  manner  the  breast  may  be  entirely  covered. 

Strapping  of  the  Chest. — See  chapter  on  Fractures. 

Strapping  of  Ulcers. — See  chapter  on  Ulcers. 

Strapping  of  Joints. — See  chapter  on  Sprains. 


FlG.  177. — Strapping  of  the  breast. 


422  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

LOCAL  APPLICATION   OF  HEAT. 

Local  heat  is  employed  to  treat  inflammation,  to  allay  pain,  to  arrest 
itching,  to  stop  hemorrhage,  to  render  joint-adhesions  soft  and  elastic, 
to  destroy  infected  areas  or  malignant  growths.  It  may  be  applied  as 
intermittent  or  continuous  heat.  The  temperature  employed  varies 
with  the  method  of  application  and  the  needs  of  the  case.  It  may  be 
so  low  as  to  irritate  only  slightly  or  so  high  as  to  cauterize  the  tissue. 
We  would  divide  heat  into  two  forms — solar  and  artificial.  Solar  heat 
is  rarely  used  locally.  To  employ  it,  it  is  usually  customary- to  con- 
centrate the  rays  of  the  sun  upon  the  diseased  part  with  a  convex 
glass.  This  method  produces  powerful  counterirritation,  and  has  been 
employed  in  the  treatment  of  ulcers  and  skin-eruptions.  Artificial  heat 
is  either  dry  or  moist. 

Dry  Heat. — Dry  heat  may  be  applied  locally  by  taking  a  plate  of 
earthenware,  a  brick,  a  bag  of  salt,  a  piece  of  iron,  or  some  other 
material,  raising  its  temperature  to  the  required  degree,  and  placing  it 
upon  the  part.  If  the  material  used  is  raised  to  a  high  temperature,  it 
is  customary  to  wrap  it  with  a  blanket  or  a  piece  of  flannel  before 
placing  it  upon  the  surface  of  the  body.  Ironing  the  part  with  a  very 
warm  iron  is  useful  in  muscular  rheumatism.  A  cloth  is  laid  upon  the 
surface  of  the  body,  and  the  iron,  as  hot  as  can  be  borne,  is  passed  up 
and  down  over  the  cloth.  The  hot-salt  bag  is  a  useful  means  of  apply- 
ing heat  to  the  perineum.  Heat  may  be  developed  locally  by  friction 
with  the  hands. 

Mayor's  hammer  is  occasionally  used  to  apply  heat  locally.  The 
hammer  is  dipped  in  very  hot  water,  dried,  and  touched  again  and 
again  to  the  surface  of  the  body.  This  process  is  known  as  firing. 
The  hot-water  bag  is  the  most  generally  employed  means  of  utilizing 
local  heat.  The  bag  is  filled  with  hot  water,  and  after  the  cap  is  screwed 
down,  it  is  carefully  examined  to  see  that  it  does  not  leak.  It  is  then 
wrapped  in  a  piece  of  blanket  and  laid  upon  the  part.  It  is  customary 
to  apply  heat  in  this  manner  in  the  treatment  of  shock,  and  great  care 
must  be  taken  not  to  burn  the  patient. 

Leiter's  apparatus  contains  many  different  tubes  suitable  for  various 
parts  of  the  body.  These  tubes  are  placed  on  the  part,  and  hot  water  is 
made  to  flow  through  them.  Dry  hot  air  is  very  useful  in  chronic  joint- 
inflammations.  A  special  apparatus  is  made  for  the  purpose  of  heating 
the  air.  This  apparatus  consists  of  a  copper  cylinder,  which  contains 
perforations  to  afford  ventilation,  and  has  an  asbestos  inner  case.  One 
end  of  the  cylinder  is  closed,  and  the  other  end  is  fitted  with  a  cover 
of  thick  material,  which  contains  a  central  opening  surrounded  by  a 
drawing-string.  The  affected  extremity  is  wrapped  in  cotton  and  is 
placed  in  the  apparatus,  where  it  rests  upon  some  dry  absorbent  cotton, 
as  a  hammock,  the  drawing-string  is  tightened,  and  the  temperature  is 
raised  to  2500  or  3000  F. 

Dry  hot  air  has  been  used  by  Hollander  for  the  cauterization  of  lupus.  In  order  to 
accomplish  this  he  drives  air  through  a  red-hot  metal  tube  at  a  temperature  of  3000  C. ,  and 
directs  the  air  upon  the  part. 

The  Actual  Cautery. — In  order  to  cauterize  the  tissues,  a  metallic 
substance  so  hot  that  it  destroys  is  applied  to  the  part.     The  actual 


LOCAL   APPLLCATLON   OF  ILEAL. 


423 


cautery  is  extremely  rapid  in  action,  and  is  not  so  very  painful  if  used  at 
a  high  heat.  The  most  convenient  means  of  applying  it  is  by  the  appa- 
ratus of  Paquelin.  In  this  apparatus  the  vapor  of  benzol  is  forced  through 
the  heated  tip  of  spongioplatinum.  The  apparatus  is  prepared  for  use 
by  fitting  the  rubber  tube  attached  to  the  cautery  end  to  one  of  the 
outlets  of  the  benzol  bottle,  and  fastening  to  the  other  outlet  the  rubber 
apparatus  for  driving  air  through.  The  tip  is  heated  to  a  red  heat  in 
a  spirit-lamp,  the  vapor  of  benzol  is  forced  through  by  squeezing  the 
bulb,  and  the  metal  can  be  kept  at  a  red  heat  for  an  indefinite  period. 
Cautery  irons  can  be  used  instead  of  the  instrument  of  Paquelin.  We 
may  use  special  irons  or  an  ordinary  poker,  or,  in  some  cases,  a  heated 
steel  needle.  Irons  are  made  of  various  shapes  and  are  set  in  wooden 
handles.  They  are  heated  in  a  charcoal  fire  or  an  ordinary  range,  and 
may  be  used  white  hot,  red  hot,  or  cherry  red,  according  to  the  neces- 
sities of  the  case.  If  we  wish  to  destroy  tissue,  the  iron  is  used  red 
hot ;  if  we  use  to  counterirritate  strongly,  it  is  white  hot ;  if  we  wish 
to  arrest  bleeding,  it  is  cherry  red.  In  counterirritating  a  part  with  a 
hot  iron,  the  instrument  touches  the  skin  here  and  there,  or  is  drawn 
lightly  over  it  in  lines.  We  should  not  counterirritate  with  a  hot  iron 
over  a  bony  prominence,  an  important  nerve,  or  a  large  blood-vessel. 
When  the  cautery  is  used  to  arrest  hemorrhage,  firm  pressure  is  made 
upon  the  part  with  a  piece  of  gauze,  the  gauze  is  quickly  removed,  and 
the  cautery  is  rapidly  smeared  upon  the  surface.  The  part  is  pressed 
upon  lightly  with  a  gauze  sponge,  and,  if  blood  still  oozes,  the  cautery 
is  again  applied.  The  cautery  will  arrest  primary  hemorrhage,  but, 
unfortunately,  in  many  instances  when  the  slough  separates,  secondary 
hemorrhage  will  arise.  If  we  wish  to  use  the  cautery  in  one  of  the 
body-cavities  or  -canals,  it  is  best  used  as  a  galvanocautery,  because  an 
electrode  can  be  introduced  while  cold,  and  after  it  has  reached  the 
region  upon  which  we  desire  to  operate,  it  can  be  instantly  heated. 
The  galvanocautery  snare  is  a  useful  instrument  with  which  to  remove 
tumors  from  the  nasal  passages.  To  employ  the  galvanocautery  an 
ordinary  electric  battery  will  not  be  sufficient.  We  must  use  a  cautery 
battery — that  is,  a  battery  which  contains  large  plates  very  near 
together.  A  cautery  battery  will  keep  the  electrode  constantly  at  a 
white  heat.  Electrodes  for  the  application  of  the  galvanocautery  are 
made  of  various  shapes  and  sizes. 

Moist  Heat. — Moist  heat  may  be  applied  as  a  local  hot  pack.  In 
applying  this,  the  patient  is  wrapped  in  a  dry  blanket,  a  piece  of 
blanket  is  wrung  out  of  very  hot  water  with  the  clothes-wringer,  the 
blanket  with  which  the  patient  is  surrounded  is  raised,  the  hot  piece 
applied  to  the  seat  of  trouble  and  the  patient  again  wrapped  up  with 
the  dry  blanket.  Moist  heat  may  be  applied  by  sponging  with  hot 
water.  This  may  allay  pain  and  arrest  itching.  Soft  sponges  are  soaked 
in  water,  hot  water  squeezed  out  upon  the  part,  and  the  sponge  is  held 
for  a  minute  or  two  in  contact  with  the  part  until  it  begins  to  cool, 
when  it  is  again  filled  with  water  and  reapplied  as  before.  Immersion 
of  the  extremity  in  hot  water  is  especially  useful  in  sprains  of  a  joint. 
The  extremity  is  placed  in  a  bucket  of  hot  water,  and  small  quantities 
of  very  hot  water  are  from  time  to  time  poured  into  the  bucket  from  a 
tea-kettle.     This  gradual  addition  of  hot  water  enables  the  extremity 


424 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


'av^-r^miW^^s 


!•■«::.;.■ 
ijjjgj-.ufc&sy 

jilpiil 


to  tolerate  a  considerable  degree  of  heat.  Compression  with  gauze 
pads  soaked  in  hot  sterile  water  or  hot  normal  salt  solution  is  used 
very  constantly  by  the  surgeon  to  arrest  capillar}'  hemorrhage.  The 
plan  is  often  invaluable.  In  order  to  carry  it  out  with  success,  the 
water  should  be  at  a  temperature  of  1 1 5°   to    1200   F. 

Heat  and  moisture  are  frequently  applied  to  a  part  by  means  of  a 
poultice  or  cataplasm.  Many  materials  are  used  for  the  purpose  of 
making  poultices — flaxseed,  bread  and  milk,  potatoes,  carrots,  charcoal, 
etc. — but  at  the  present  time  the  old-fashioned  poultice  has  so  limited 
an  application  that  it  is  unnecessary  to  dwell  upon  many  of  these 
forms.  The  poultice  which  is  most  frequently  employed  is  made  of 
ground  flaxseed.  A  spoon  and  a  tin  basin  are  scalded.  The  flaxseed 
is  put  in  a  dry  hot  basin,  and  sufficient  boiling  water  is  added  to  make 

a  thick  paste.  The  material  reaches  the 
proper  consistency  when  it  is  decided  that 
the  mass  would  stick  if  it  were  thrown 
against  the  wall.  It  is  spread  to  the  thick- 
ness of  \  inch  upon  a  piece  of  muslin,  and 
is  covered  with  cheese-cloth  to  prevent  ad- 
hesion to  the  skin.  When  it  is  laid  upon 
the  part,  it  is  covered  with  oiled  silk  or 
with  wax  paper.  Such  a  poultice  will  re- 
tain its  heat  for  five  or  six  hours.  Lint  or 
spongiopilin  soaked  in  hot  water,  laid  upon 
the  part,  and  covered  with  an  impermeable 
material,  makes  an  excellent  poultice.  The 
fermented  poultice  which  was  once  exten- 
sively used  for  gangrenous  processes  was  made  by  sprinkling  yeast 
over  an  ordinary  cataplasm.  A  charcoal  poultice  was  made  by  stir- 
ring charcoal  into  the  poultice  mass.  A  sedative  poultice  contains 
2  grains  of  opium  to  the  ounce  of  poultice  mass.  A  part  must  not  be 
poulticed  too  long,  especially  in  adynamic  conditions,  because  vesication 
or  pustulation  may  result ;  and  a  wound  should  never  be  poulticed 
except  by  antiseptic  fomentations. 

Hot  fomentations  or  hot  compresses  are  used  particularly  to  allay 
pain,  to  treat  inflammation,  and  to  restore  the  circulation  of  damaged 
areas.  A  hot  fomentation  is  applied  as  follows  :  Flannel  is  folded  into 
several  thicknesses  and  is  wrung  out  of  water  at  a  temperature  of 
120°  F.  It  is  then  laid  upon  the  part,  covered  with  oiled  silk  or  wax 
paper,  and  changed  as  soon  as  it  begins  to  cool.  It  can  be  kept  warm 
for  hours  by  placing  a  hot-water  bag  upon  the  part  over  the  flannel, 
such  a  dressing  being,  in  reality,  an  excellent  form  of  poultice.  An 
antiseptic  fomentation  or  an  antiseptic  poultice  is  used  when  it  is  neces- 
sary to  apply  heat  and  moisture  to  a  wound,  to  an  ulcer,  or  to  a  gan- 
grenous process.  An  antiseptic  fomentation  is  made  by  soaking  a  piece 
of  sterile  gauze  in  a  hot  solution  of  corrosive  sublimate  (i  :  iooo),  wring- 
ing it  out,  placing  it  upon  the  part,  covering  it  with  oiled  silk,  and 
laying  outside  of  it  a  hot-water  bag. 

Steam  has  been  used  locally  by  some  practitioners.  Kahn  has  employed  it  in  puer- 
peral endometritis.  He  attaches  a  hose  by  one  end  to  a  kettle,  by  the  other  to  a  uterine 
applicator  which  has  a  hollow  stem.      The  kettle  is  furnished  with  a  thermometer  and  a 


Fig.  178. — Emollient  poultice. 


LOCAL   APPLICATION  OF  HEAT.  425 

spirit-lamp.  The  steam  is  used  for  two  minutes  at  ioo°  C,  and  then  for  one  minute  at 
115°  C,  and  it  causes  but  little  pain.  For  several  days  after  it  has  been  used  intra-uterine 
douches  are  given.  Steam  has  also  been  used  for  the  purpose  of  disinfecting  bone-cavities, 
and  boiling  oil  and  boiling  water  have  been  employed  with  the  same  end  in  view.  These 
agents,  unfortunately,  invariably  cause  superficial  necrosis. 

Counterirritants. — Irritation  of  the  surface  of  the  body  may  be 
used  for  the  purpose  of  benefiting  internal  derangements.  We  must 
be  very  cautious  in  using  counterirritants  if  a  person  is  lethargic,  stu- 
porous, or  comatose,  because  in  this  condition  we  may  do  great  injury, 
the  individual  feeling  no  pain,  and  being  unable  to  call  our  attention 
to  the  destruction  which  is  going  on.  Counterirritants  should  not  be 
applied  to  paralyzed  parts.  Counterirritants  are  divided  into  rubefa- 
cients, agents  which  cause  heat  and  redness  ;  epispastics,  agents  which 
cause  inflammation  and  vesication  ;  and  cauterants,  agents  which  imme- 
diately destroy  the  tissues.  The  most  commonly  used  rubefacient  is 
ground  mustard.  The  hot  mustard  foot-bath,  which  is  a  useful  domes- 
tic remedy,  is  made  by  adding  two  tablespoonfuls  of  ground  mustard  to 
a  basin  of  warm  water ;  and  in  this  mixture  the  patient  places  his  feet. 
The  water  must  be  below  ioo°  F.,  because  hot  water  will  destroy  the 
ferment  myrosin,  and,  as  a  consequence,  the  volatile  oil  of  mustard, 
which  is  the  rubefacient  element,  will  not  be  formed.  Mustard  is  gen- 
erally used  in  the  form  known  as  a  mustard  piaster.  To  make  a  mus- 
tard plaster  for  an  adult,  take  equal  parts  of  ground  mustard  and  of 
flaxseed  meal  and  make  them  into  a  thick  paste  with  tepid  water. 
The  mixture  is  spread  on  old  muslin,  is  covered  with  cheese-cloth, 
is  laid  upon  the  part,  and  kept  on  from  fifteen  to  thirty  minutes.  Occa- 
sionally mustard  will  form  vesicles,  and  if  such  an  accident  happens, 
the  vesicated  area  should  be  dressed  with  cosmolin  or  zinc  ointment. 
In  order  to  make  a  mustard  plaster  for  a  child,  1  part  of  mustard  is 
added  to  3  parts  of  flaxseed  meal.  The  ready-prepared  mustard 
plasters  of  the  shops  are  known  as  mustard  papers.  They  are  deci- 
dedly strong.  In  order  to  prepare  one  for  use,  it  should  be  dipped  into 
tepid  water,  the  mustard  side  covered  with  a  piece  of  cheese-cloth,  and 
the  plaster  laid  upon  the  part. 

Counterirritation  can  be  effected  by  hot  fomentations  or  the  use  of 
Mayor's  hammer,  to  which  allusion  has  already  been  made.  Spirit  of 
turpentine  is  a  useful  agent  with  which  to  counterirritate.  It  may  be 
rubbed  upon  the  part  in  its  pure  condition  or  may  be  mixed  with  an 
equal  part  of  olive  oil.  The  turpentine  stupe  is  very  useful.  It  is  pre- 
pared as  follows  :  Take  a  flannel  cloth,  fold  it  in  several  layers,  wring  it 
out  in  hot  water,  sprinkle  upon  it  5  to  10  drops  of  spirit  of  turpentine, 
lay  it  upon  the  part,  and  bind  it  on  with  a  bandage.  Instead  of  flannel, 
spongiopilin  may  be  used. 

The  spice  bag  is  a  very  common  domestic  means  of  obtaining 
counterirritation.  It  is  a  mild  rubefacient,  and  can  be  kept  on  a 
part  for  many  hours.  It  is  made  by  mixing  equal  parts  of  nutmegs, 
cloves,  cinnamon,  and  allspice,  and  half  of  a  part  of  black  pepper. 
This  mixture  is  sewed  up  in  a  flat  bag  of  old  linen.  The  bag  is  quilted 
to  prevent  sagging  of  the  contents.  One  side  of  the  bag  is  wet  with 
vinegar,  warm  brandy,  or  whiskey,  and  is  laid  upon  the  part.  Counter- 
irritation may  also  be  effected  by  touching  the  part  lightly  with  the 
cautery,  by  friction  with  stimulating  liniments — for  instance,  camphor 


426  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

liniment,  soap  liniment,  or  turpentine  liniment ;  or  by  the  use  of  capsi- 
cum plaster,  Burgundy-pitch  plaster,  Canada-pitch  plaster,  or  arnica 
plaster.  Epispastics  arc  used,  particularly  in  chronic  pleuritic  effusion, 
in  chronic  inflammation  of  joints,  and  in  inflammation  of  tendon-sheaths 
and  bursse. 

Before  blistering  a  part,  it  should  be  washed  and  dried  ;  if  it  is 
hain-,  it  should  be  shaved.  The  favorite  material  for  blistering  is  can- 
tharides, which  may  be  used  in  the  form  of  the  cerate,  the  cantharides 
paper,  or  cantharidal  collodion.  If  we  use  the  cerate,  it  should  be 
spread  on  the  center  of  a  piece  of  adhesive  plaster,  free  margins  of 
adhesive  plaster  being  left  to  adhere  to  the  surface  of  the  body.  If  a 
very  prompt  effect  is  desired,  just  before  the  blistering  material  is 
applied,  the  skin  should  be  rubbed  for  a  minute  or  two  with  spirit  of 
turpentine.  Blisters  form  on  children  more  easily  than  upon  adults, 
and  in  children  it  is  wise  to  interpose  a  piece  of  thin  tissue  paper 
between  the  cerate  of  cantharides  and  the  skin.  In  the  adult,  the 
blistering  material  is  left  in  place  for  six  hours  and  is  then  removed, 
and,  if  the  blister  is  not  found  thoroughly  developed,  the  part  is  poul- 
ticed for  some  hours.  If  the  patient  resents  the  pain,  is  very  nervous, 
or  in  a  debilitated  condition,  the  blistering  material  is  removed  in  two 
hours,  and  a  flaxseed  poultice  applied.  When  the  blister  is  fully  devel- 
oped, it  is  punctured  at  its  most  dependent  portion  to  permit  of  drain- 
age, and  is  dressed  with  cosmolin  or  ointment  of  oxid  of  zinc.  If 
we  wish  to  keep  the  blister  open,  the  stratum  corneum  is  cut  away, 
and  the  blister  is  dressed  with  an  irritant  application,  such  as  5 
drops  of  nitric  acid  to  the  ounce  of  cosmolin.  If  cantharidal  col- 
lodion is  used  to  make  a  blister,  several  layers  of  it  are  painted 
upon  a  part  by  means  of  a  camel's-hair  brush.  If  cantharidal  paper  is 
employed,  it  is  cut  to  the  proper  size,  greased  with  olive  oil,  laid  upon 
the  part,  and  held  in  position  by  rubber  adhesive  plaster.  Blisters  can 
be  formed  rapidly  by  the  use  of  stronger  ammonia.  If  a  few  drops  are 
poured  into  a  watch-crystal,  and  the  crystal  is  laid  upon  the  surface,  a 
blister  will  form  in  fifteen  minutes.  A  piece  of  lint  can  be  saturated 
with  ammonia,  and,  after  being  laid  upon  the  surface,  covered  with 
oiled  silk.  Equal  parts  of  ammonia  and  lard  will  blister  in  five  min- 
utes. Chloroform  will  rapidly  blister.  It  is  applied  by  moistening 
lint  with  the  chloroform,  placing  the  lint  on  the  part,  and  covering  it 
with  oiled  silk  or  a  watch-glass.  If  a -solid  stick  of  silver  nitrate  is 
drawn  across  a  part,  it  will  vesicate.  Tartar  emetic  ointment  may  be 
used  for  the  same  purpose.  The  hot  iron  at  a  white  heat,  brought 
near  to  the  surface,  will  instantly  vesicate.  After  this  has  been  used, 
the  vesicated  area  is  dressed  with  iced  water  for  an  hour,  and  is  then 
poulticed.  The  older  surgeons  used  to  employ  Vienna  paste.  This 
consists  of  5  parts  of  caustic  potash  and  6  parts  of  lime,  made  into  a 
paste  with  alcohol.  It  will  blister  in  five  minutes  ;  when  it  has  made  a 
blister,  it  is  w7ashed  off  with  vinegar. 

LOCAL  APPLICATION  OF  COLD. 

Cold  is  used  to  contract  the  vessels  in  inflammation,  to  arrest  swell- 
ing, to  allay  pain,  and  to  stop  hemorrhage.     It  may  be  used  as  inter- 


AXESTHETICS  IN  MINOR   SURGERY.  427 

mittent  or  continuous  cold,  and  also  in  the  form  of  wet  cold  or  of  dry 
cold. 

Wet  cold  can  be  used  in  the  form  of  continuous  irrigation.  In 
order  to  apply  irrigation,  the  part  should  be  wrapped  in  wet  linen  and 
laid  on  a  rubber  sheet  folded  into  a  trough,  the  end  of  the  trough 
emptying  into  a  bucket.  A  vessel  filled  with  cold  water  is  placed  on  a 
shelf  which  is  on  a  higher  level  than  the  bed.  A  wet  lamp-wick  can 
be  carried  from  the  reservoir  to  the  part.  The  part  will  be  kept  wet 
because  capillary  attraction  and  gravity  lead  water  from  the  reservoir. 
Evaporation  greatly  lowers  the  temperature.  Instead  of  a  lamp-wick, 
a  rubber  tube  may  be  used  to  carry  the  fluid,  a  clamp  being  set 
upon  the  tube  to  regulate  the  amount  of  flow.  The  fluid  used  may 
be  ordinary  water,  spring  water,  or  iced  water.  If  the  water  be  too 
warm,  it  can  be  reduced  to  a  temperature  of  45 °  F.  by  the  addition 
of  1  part  of  alcohol  to  4  parts  of  water.  Great  cold  can  be  obtained 
by  the  use  of  a  mixture  of  5  parts  of  potassium  nitrate,  5  parts  of 
ammonium  chlorid,  and  16  parts  of  water.  If  wet  cold  is  used  upon 
an  open  wound,  the  wound  and  the  adjacent  skin  must  be  thoroughly 
asepticized  and  covered  with  gauze  which  is  wet  in  an  antiseptic  solu- 
tion ;  the  fluid  itself  must  be  antiseptic,  or  at  least  sterile.  Compresses 
soaked  in  iced  water  and  frequently  changed  are  very  useful  in  the 
treatment  of  conjunctivitis  and  epididymitis. 

Dry  cold  is  usually  employed  in  the  form  of  an  ice-bag.  A  rubber 
bag  or  a  bladder  is  filled  with  finely  cracked  or  ground  ice.  The  bag 
is  not  laid  directly  upon  the  part,  because  it  invariably  becomes  moi>t ; 
a  piece  of  flannel  is  always  interposed  between  the  bag  and  the  skin. 
The  part  may  be  encircled  with  a  rubber  tube  through  which  cold 
water  flows  ;  or  Leiter's  tubes  may  be  employed,  or  pieces  of  metal, 
which  have  been  chilled  by  soaking  in  a  cold  fluid,  may  be  laid  upon 
the  diseased  area. 

ANESTHETICS  IN  MINOR  SURGERY. 
In  minor  operations  it  may  be  necessary  or  convenient  to  administer 
ether  or  chloroform  exactly  as  is  done  in  a  major  operation.  In  some 
cases  a  general  anesthetic  other  than  ether  or  chloroform  is  employed, 
and  in  many  cases  only  local  anesthesia  is  necessary.  If  ether  or  chlo- 
roform is  used,  the  same  care  is  taken  and  the  same  precautions  are 
observed  as  in  a  major  operation.  The  fact  that  the  operation  is  trivial 
does  not  mean  that  an  anesthetic  has  slighter  dangers  than  usual. 
Many  of  the  accidents  which  have  occurred  during  anesthesia  have 
arisen  during  the  performance  of  small  operations.  The  temptation  in 
such  cases  is  to  operate  before  the  reflexes  are  abolished ;  and,  when 
the  reflexes  are  not  abolished,  a  violent  peripheral  irritation  may  pro- 
duce cardiac  or  respiratory  inhibition,  and  such  an  accident  is  most  apt 
to  occur  when  an  operation  involves  the  trajectory  of  the  fifth  nerve. 
In  truth,  incomplete  anesthesia  is  a  condition  of  greater  danger  than  is 
complete  anesthesia. 

Ethyl  Bromid. — Ethyl  bromid  very  rapidly  produces  anesthesia,  and,  after  the  admin- 
istration is  suspended,  consciousness  is  quickly  regained.  The  drug  should  be  kept  in  a 
tightly  stoppered  yellow  glass  bottle.    A  child  can  be  given  3  drams,  and  an  adult  6  drams.1 

1  Cumston,  Boston  Med.  and  Surg.  Jour.,  July  20,  1894. 


428  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

In  administering  ethyl  bromid,  the  entire  amount  to  be  given  is  poured  on  a  folded  towel 
or  an  Esmarch  mask,  and  the  mask  or  towel  held  closely  to  the  mouth  and  nose,  so  as  to 
exclude  air.  Unconsciousness  can  be  produced  in  from  half  a  minute  to  two  minutes.  The 
moment  the  patient  becomes  unconscious,  the  inhaler  is  removed,  and  the  operation  is  pro- 
ceeded with.  It  will  be  unsafe  to  give  more  of  the  anesthetic,  because  the  administration 
of  a  larger  amount  of  ethyl  bromid  will  produce  muscular  contractures,  rigidity  of  the  jaw, 
and  irregularity  of  respiration.  After  the  withdrawal  of  the  inhaler,  the  patient  will  remain 
unconscious  for  about  three  minutes,  and  will  then  promptly  return  to  consciousness 
(Cumston). 

There  are  very  rarely  any  disagreeable  after-effects.  The  safety  of  this  drug  has  been  a 
matter  of  some  question.  Sudden  death  has  happened  from  its  use.  Cumston  has  used  it 
in  200  cases,  and  believes  it  to  be  absolutely  safe  ;  but  he  says  that  serious  lesions  of  the  kid- 
neys, lungs,  or  heart  are  contra-indications  to  its  use.  Lauder  Brunton  does  not  consider  the 
drug  absolutely  safe.      The  author  has  knowledge  of  I  death  produced  by  it. 

Nitrous  Oxid. — Many  minor  operations  can  be  performed  when 
the  patient  is  under  the  influence  of  nitrous  oxid.  This  agent  can  be 
given  alone  or  combined  with  oxygen  gas.  The  administration  of 
nitrous  oxid  requires  a  rather  bulky  and  expensive  apparatus,  and  the 
gas  is  not  readily  applied  in  private  houses  ;  so  that,  if  it  is  desired  to 
use  it,  the  patient  is  usually  taken  to  a  hospital  or  to  a  dentist's  office. 
An  impediment  to  the  extensive  use  of  nitrous-oxid  gas  has  always 
been  the  brevity  of  the  anesthetic  state  which  it  induces  and  the  danger 
of  prolonging  the  anesthesia  by  continuous  administration.  Paul  Bert 
some  time  since  discovered  that  if  nitrous  oxid  were  mixed  with  oxygen, 
and  an  animal  were  placed  in  a  chamber  in  which  pressure  was  increased, 
anesthesia  could  be  kept  up  indefinitely  with  safety.  Since  then  it 
has  been  made  evident  that  it  is  not  necessary  to  increase  atmospheric 
pressure,  and  that  a  mixture  of  equal  parts  of  the  gas  and  of  oxygen 
can  be  continuously  inhaled  and  will  produce  prolonged  anesthesia 
(Hewitt's  apparatus).  If  oxygen  and  nitrous  oxid  are  so  given,  there 
will  be  from  thirty  to  forty  seconds  of  available  anesthesia  after  the 
removal  of  the  face-mask  ;  but  with  this  mixture  anesthesia  can  be 
maintained  while  an  operative  procedure  of  some  length  is  being  car- 
ried on.  Ordinarily,  nitrous  oxid  is  not  to  be  used  as  an  anesthetic  in 
the  reduction  of  a  dislocation,  the  setting  of  a  fracture,  the  examination 
of  a  joint,  or  the  stretching  of  the  sphincter,  because  it  causes  muscular 
rigidity  ;  but  nitrous  oxid  mixed  with  oxygen  does  not  produce  rigidity. 

Primary  Anesthesia. — Where  ether  is  rapidly  inhaled, "  there 
arises  in  many  cases  a  temporary  condition,  in  the  early  period  of  the 
administration,  in  which  the  patient  is  confused,  but  not  unconscious, 
and  yet  has  no  appreciation  of  pain.  This  stage  is  known  as  primary 
anesthesia.  It  lasts  about  thirty  seconds,  and  during  its  continuance  a 
simple  operation,  like  the  opening  of  an  abscess,  may  be  performed 
without  pain.  In  order  to  induce  primary  anesthesia  the  patient  should 
be  recumbent,  with  one  arm  raised  vertically.  He  should  count  out 
loud.  An  Allis  inhaler  is  placed  over  the  mouth  and  nose,  and  ether 
is  poured  on  steadily.  In  a  little  time  the  counting  becomes  irregular 
and  confused,  or  is  stopped  entirely ;  the  arm  drops  to  the  side,  and  the 
time  has  come  for  operating. 

I/OCal  Anesthesia. — Local  anesthesia  can  be  induced  by  cold. 
Cold  may  be  brought  to  bear  upon  a  part  by  the  use  of  ice  and  salt 
(Arnott's  plan),  the  injection  of  iced  water,  spraying  the  part  with  ether 
(Benjamin  Ward  Richardson),  with  rhigolene  (Bigelow),  or  with  ethyl 
chlorid.     If  ice  is  used,  it  is  to  be  broken  up  very  fine,  and  1   part  of 


ANESTHETICS  IN  MINOR   SURGERY. 


429 


salt  is  mixed  with  2  parts  of  ice.  The  mixture  is  wrapped  up  in  a 
piece  of  cheese-cloth  and  laid  upon  the  part.  In  about  fifteen  or 
twenty  minutes  the  skin  blanches,  and  the  part  is  ready  for  operation. 
The  spray  of  ethyl  chlorid  is  the  most  rapid  and  convenient  means  of 
freezing.  The  drug  is  furnished  in  a  glass  tube  with  a  narrow  neck, 
which  is  kept  closed  with  a  brass  screw-piece  (Bengue's  apparatus). 
When  a  part  is  to  be  frozen,  the  brass  cap  is  removed,  and  the  tube  is 
held  in  the  palm  of  the  hand,  so  as  to  warm  it.  A  fine  spray  of  ethyl 
chlorid  is  projected  through  a  small  opening  in  the  neck  of  the  bulb  and 
thrown  upon  the  surface  to  be  frozen.  The  tube  should  be  held  8  to 
10  inches  from  the  skin  of  the  patient.  As  the  skin  freezes,  it  suddenly 
whitens  ;  it  will  remain  anesthetic  for  several  minutes.  Freezing  of  the 
part,  no  matter  how  it  is  brought  about,  is  in  most  instances  not  thor- 
oughly satisfactory.  Of  necessity,  a  larger  area  is  frozen  than  requires 
to  be  cut.  The  freezing  makes  the  tissues  hard  and  difficult  to  divide, 
and  alters  very  much  their  appearance.  The  process  of  freezing  is 
itself  painful,  and,  occasionally,  sloughing  follows  the  procedure. 

Freezing  is  satisfactory  only  when  we  wish  to  make  a  small  incision 
or  a  puncture — for  instance,  opening  an  abscess,  tapping  a  hydrocele,  or 
penetrating  the  skin  with  a  needle  to  introduce  Schleich's  fluid.  Local 
anesthesia  can  be  obtained  to  a  certain  extent  by  the  use  of  electricity. 
This  has  been  particularly  employed  in  dentistry.  In  some  cases 
needles  are  introduced  into  the  tissues  and  the  current  is  passed.  In 
other  cases,  the  electric  current  is  used  to  carry  cocain  into  the  tissues 
(electrical  cataphoresis).  Local  anesthesia  may  be  induced  by  the 
local  application  of  certain  drugs.  In  some  cases,  the  agent  is  applied 
to  the  surface ;  in  others,  it  is  injected  into  the  tissues. 

Cocain. — Cocain  is  a  very  useful  agent,  ft  will  anesthetize  mucous 
membranes  if  applied  to  the  surface,  but  to  affect  the  skin  and  deeper 
structures  the  drug  must  be  injected.  It  is  instilled  into  the  conjunc- 
tival sac,  injected  into  the  urethra  and  bladder,  painted  upon  the  larynx, 
and  sprayed  into  the  nares.  In  the  vast  majority  of  cases  the  use  of 
cocain  is  productive  of  no  harm.  In  many  cases  it  produces  slight 
toxic  symptoms.  In  some  cases  grave  symptoms  follow  its  use,  and 
in  a  few  reported  cases  it  has  produced  death  (see  chapter  on  Anesthetics). 
Injection  about  the  head  is  more  dangerous  than  in  other  regions  (Wolf- 
ler).  A  warm  solution  is  more  efficient  than  a  cold  solution,  and  as  less 
of  it  will  produce  anesthesia,  it  is  the  safer.  Because  of  the  dangers 
which  possibly  reside  in  cocain,  it  should  be  administered  while  the 
individual  is  recumbent,  and  at  the  first  sign  of  trouble,  active  treat- 
ment should  be  instituted  (see  chapter  on  Anesthetics).  In  anesthetizing 
the  eye,  the  strength  of  the  solution  of  cocain  varies  from  1  to  4  per 
cent.,  according  to  the  depth  and  duration  of  anesthesia  required.  If 
a  foreign  body  is  to  be  removed  from  the  surface,  a  1  per  cent,  solution 
is  used.  If  a  cataract  is  to  be  extracted,  a  4  per  cent,  solution  is 
employed.  A  drop  or  so  of  the  fluid  is  instilled  every  ten  minutes, 
until  three  instillations  have  been  made ;  the  parts  will  then  be  entirely 
insensitive.  In  the  nose,  pharynx,  larynx,  and  tonsils,  the  strength 
of  the  solution  varies  from  2  to  20  per  cent.  A  strong  solution  is 
far  safer  when  used  in  the  larynx  than  in  the  pharynx  or  esoph- 
agus.     Over  ^  grain  must  not  be  injected  under  the  mucous  mem- 


430  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

brane  of  the  mouth  (Stoerk).  Over  |  grain  should  not  be  applied 
to  a  mucous  surface.  In  the  urethra  a  4  per  cent,  solution  is  in- 
jected; in  the  bladder  a  2  per  cent,  solution  is  used.  For  the  vulva, 
vagina,  and  uterus  a  5  per  cent,  solution  is  employed  ;  for  the  rectum 
a  5  per  cent,  solution  is  employed,  pieces  of  cotton  being  saturated 
with  the  drug  and  introduced  into  the  rectum.  To  secure  insensibility 
of  the  skin,  cocain  must  be  injected  with  a  hypodermic  syringe.  The 
solution  should  be  of  the  strength  of  1  or  2  per  cent.,  and  it  is  desirable 
to  have  it  warm.  More  than  \  grain  should  never  be  injected,  especially 
about  the  face  and  genitals.  The  surgeon  should  be  careful  not  to 
throw  the  drug  into  a  vein.  The  injection  is  made  into  the  skin,  but 
not  into  the  subcutaneous  areolar  tissue.  Injection  into  the  subcutane- 
ous tissue  is  both  dangerous  and  unsatisfactory. 

Method  of  Injection. — If  the  region  is  suitable,  a  rubber  band  should 
be  applied  above  the  seat  of  operation.  A  sharp  needle  is  placed  at  an 
angle  of  45 °  to  the  surface  and  pushed  through  the  epiderm  and  into, 
but  not  through,  the  Malpighian  layer.  A  minim  or  so  of  the  solu- 
tion is  forced  out  of  the  syringe.  A  whitened  elevation  will  be  formed. 
The  needle  is  withdrawn,  and  at  the  margin  of  the  whitened  area  and 
in  the  direction  in  which  the  incision  is  to  be  made,  the  needle  is 
inserted  again  and  another  minim  or  so  forced  out.  When  the  area 
which  is  to  be  operated  on  has  been  injected,  the  surgeon  waits  five 
minutes  and  then  procasds  with  the  operation.  After  the  skin  has  been 
divided,  if  it  is  necessary  to  cut  the  subcutaneous  tissues,  a  few  drops 
of  a  1  per  cent,  solution  of  cocain  are  poured  into  the  wound  from 
time  to  time.  After  the  completion  of  the  operation,  the  constricting 
band  is  loosened  for  several  seconds  and  readjusted  for  several  minutes. 
Again  it  is  loosened  and  readjusted,  and  so  on  three  or  four  times 
(Wyeth).  In  this  way  but  a  small  quantity  of  cocain  is  taken  into  the 
system  at  one  time,  the  organism  is  able  to  distribute  it  and  dispose 
of  it,  and  no  toxic  symptoms  arise.  Corning  demonstrated  that  if  the 
arteriovenous  circulation  is  arrested,  the  action  of  cocain  can  be  very 
greatly  prolonged.  His  method  is  as  follows  :  A  piece  of  elastic  web- 
bing is  applied  temporarily  around  the  limb  above  the  field  of  opera- 
tion, the  course  of  the  veins  is  marked  with  a  colored  pencil,  the  web- 
bing removed,  Esmarch's  bandage  applied  from  the  periphery  to  the 
lower  margin  of  the  field  of  operation,  a  flat  rubber  band  applied 
around  the  limb  at  the  upper  margin  of  the  field  of  operation,  the 
Esmarch  bandage  removed,  and  the  cocain  injected  as  previously 
directed.  The  anesthetic  condition  can  be  maintained  by  this  method 
for  over  an  hour. 

If  operating  upon  the  back,  abdomen,  breast,  or  head,  Corning  con- 
trols the  circulation  by  the  application  of  rings  of  rubber  around  the 
field  of  operation,  the  rings  being  held  so  as  to  press  down  upon  the 
surface  by  means  of  bands.  Krogius  has  pointed  out  that  cocain,  if 
injected  into  the  tissue  near  a  nerve-trunk,  produces  in  five  minutes 
anesthesia  in  the  peripheral  distribution  of  the  nerve.  Anesthesia  so 
produced  lasts  fifteen  minutes,  and  operations  in  this  area  can  be  pain- 
lessly performed.  All  the  tissues  of  the  finger,  both  superficial  and 
deep,  can  be  rendered  anesthetic  by  injecting  cocain  across  the  root  of 
the  digit.     Analgesia  of  the  middle  of  the  forehead  is  caused  by  inject- 


ANESTHETICS  IN  MINOR   SURGERY. 


431 


ing  a  drug  over  both  supra-orbital  notches.  Injection  over  the  ulnar 
nerve  causes  anesthesia  of  the  entire  nerve-distribution.  This  plan  has 
been  used  extensively  in  the  clinic  at  Helsingfors,  and  over  200  opera- 
tions have  been  performed  (amputation  of  the  finger,  the  toe,  circum- 
cision, etc.). 

Schleich's  Infiltration  Anesthesia. — Schleich  was  impressed  with 
the  facts  that  not  only  is  cocain  sometimes  dangerous,  but  it  is  often 
unsatisfactory,  because  it  is  not  diffused  widely  enough  to  anesthetize 
anastomosing  nerve-fibers.  It  was  long  ago  pointed  out  by  Leibreich 
that  an  injection  of  water  produces  anesthesia,  but  also  causes  pain 
(painful  anesthesia).  Schleich  found  that  injection  of  normal  salt  solu- 
tion produces  no  pain  and  causes  no  anesthesia ;  but  if  0.2  of  a  1  per  cent, 
solution  is  injected  no  pain  is  produced,  but  the  part,  if  uninflamed, 
becomes  distinctly  anesthetic.  In  order  to  obtain  anesthesia  from  salt 
solution,  the  area  must  be  infiltrated  and  distended.  This  anesthesia  is 
due  to  pressure  and  to  slight  irritation  of  the  nerves.  Schleich  found, 
further,  that  if  minute  quantities  of  cocain,  carbolic  acid,  and  mor- 
phin  are  added  to  the  salt  solution,  the  anesthetic  effect  is  greatly 
intensified  and  prolonged,  and  can  be  distinctly  obtained  even  in  inflamed 
tissues. 

The  reason  that  such  dilute  solutions  of  these  drugs  have  a  distinct 
anesthetic  influence  is  because  the  process  of  infiltration  brings  the 
fluLd  into  direct  contact  with  all  the  nerve-filaments  of  a  considerable 
area.  Schleich  uses  one  of  three  solutions,  all  of  which  are  sterile, 
should  be  recently  made,  and  should  be  cooled  on  ice  just  before 
using. 

Solution  No.  I  is  the  strong  solution,  and  is  used  for  operations 
upon  inflamed  and  hyperesthetic  areas.     It  is  composed  of — 

II   Cocain.  mur.,  .20; 

Morph.  mur.,  .025  ; 

Sodii  chlor.,  .20 ; 

Aq.  dest,  ad  100.00. 

Sterilize  solution,  and  add  gtt.  ij  of  5  per  cent,  carbolic  acid. 

Solution  No.  2  is  the  one  commonly  employed.     This  consists  of — 

I$i   Cocain.  mur.,  .10; 

Morph.  mur.,  .025  ; 

Sodii  chlor.,  .20; 

Aq.  dest,  ad  100.00. 

Sterilize,  and  add  carbolic  acid  as  above  directed. 

The  third  solution  is  mild  and  employed  for  slight  operations  upon 
nearly  normal  tissues.     It  consists  of — 

I$s  Cocain.  mur.,  .01  ; 

Morph.  mur.,  .005  ; 

Sodii  chlor.,  .20; 

Aq.  dest,  100.00. 

Sterilize,  and  add  carbolic  acid  as  above  directed. 

MetJiod. — An  ordinary  aseptic  hypodermic  syringe  is  employed.  It 
is  well  to  freeze  with  ethyl  chlorid  the  point  of  skin  where  the  needle 


43^ 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


is  to  be  first  inserted.  In  dealing  with  a  mucous  membrane,  instead  of 
freezing  it  should  be  touched  with  pure  carbolic  acid,  or  with  a  little 
cocain.  If  the  tissues  are  inflamed,  the  first  injection  should  be  made 
in  sound  tissue,  and  the  subsequent  ones  in  inflamed  tissue.  The 
needle  is  inserted  obliquely,  and  its  entire  length  is  carried  into  the 
Malpighian  layer  (Fig.  l8o);  a  few  drops  are  forced  out,  and  a  white 


FIG.  180. — The  syringe-point  stops  at  the  papillary  layer, 
and  the  fluid  lodges  in  the  skin  itself  (Van  Hook). 


Fig.  179. — Showing  how  the 
successive  wheals  are  raised,  the 
point  of  the  syringe  being  inserted 
at  the  points  marked  by  the  dots 
(Van  Hook). 


FIG.  181. — Showing  mode  of  injecting  the  fluid  under  an 
abscess  (Van  Hook). 


wheal,  looking  like  a  mosquito  bite,  is  formed  (Van  Hook).  The  area 
occupied  by  the  wheal  becomes  at  once  anesthetic.  At  the  margin  of 
the  wheal  the  needle  is  reinserted,  more  fluid  is  forced  out,  and  the 
process  is  carried  on  in  this  way  until  the  required  area  is  infiltrated 
(Fig.  179).  The  skin  will  remain  anesthetic  for  at  least  twenty  minutes. 
If  other  structures  besides  the  skin  require  to  be  anesthetized,  the 
needle  is  pushed  into  the  deeper  tissues  and  they  are  infiltrated.  Lund 
says  that  the  infiltration  should  be  around  and  underneath  the  tissues, 
so  as  to  encompass  them  with  artificial  edema.  Fascia,  muscles,  and 
periosteum  can  be  anesthetized  as  well  as  the  skin  (Van  Hook).  When 
the  anesthesia  is  complete,  the  skin  is  incised  and  the  operation  is  pro- 
ceeded with.  If  a  nerve-trunk  is  exposed,  it  should  be  touched  with 
pure  carbolic  acid  (Schleich).  There  will  be  very  little  bleeding,  but  if 
it  becomes  necessary  to  clamp  a  vessel  before  applying  the  forceps,  it 
should  be  touched  with  pure  carbolic  acid.  Injections  can  be  made 
into  an  abscess-wall,  but  are  never  made  into  an  abscess-cavity,  the  sac 
of  a  cyst,  or  the  tissue  of  a  tumor  (Lund).  Tissues  which  have  been 
subjected  to  infiltration  seem  to  have  their  vital  resistance  lessened,  and 
are  more  liable  to  infection  than  are  non-infiltrated  tissues. 

Eucain. — Eucain   is   used  in   the   same   manner  as   cocain,  and  is 


LOCAL    BLOOD-LETTLNG.  433 

extensively  employed  as  a  substitute  for  the  latter.  It  has  great 
advantages.  It  is  decidedly  safer  than  cocain ;  a  solution  of  it  can  be 
rendered  sterile  by  boiling,  without  altering  the  composition  of  the 
drug,  and  it  produces  complete  insensibility.  When  used  in  the  eye  it 
produces  considerable  smarting  and  burning,  and  when  used  in  the 
urethra  and  bladder  may  lead  to  inflammation.  In  a  certain  number 
of  cases,  injection  into  the  tissues  causes  persistent  sloughing.  This  is 
particularly  true  in  fatty  tissue,  in  the  matrix  of  the  nails,  in  bursae,  and 
in  tendon-sheaths.  This  tendency  to  cause  sloughing  in  some  cases  is 
the  only  objection  to  its  employment,  and  is  apparently  the  only  reason 
why  it  does  not  completely  displace  cocain. 

LOCAL  BLOOD-LETTING. 

Bleeding  may  be  practised  for  its  local  effect ;  it  is  then  known  as 
local  bleeding  or  depletion.  It  may  be  employed  for  its  constitutional 
effect,  and  it  is  then  known  as  phlebotomy  or  venesection.  Local 
bleeding  may  be  carried  out  by  puncture,  by  scarification,  by  leeching, 
or  by  cupping.  In  puncturation  or  puncture  many  punctures  are  made 
through  the  skin,  and  they  are  not  carried  deeper  than  the  subcutaneous 
tissue.  The  punctures  can  be  made  by  means  of  a  tenotome,  a  needle, 
or  a  sharp-pointed  bistoury.  When  numerous  punctures  are  made,  the 
procedure  is  often  spoken  of  as  multiple  puncture.  Puncture  is  not 
only  useful  in  abstracting  blood  locally,  but  it  also  relieves  tension  in 
regions  of  inflammation.  By  scarification  or  incision  we  mean  the 
making  of  many  small  incisions.  These  cuts  may  be  deep,  but,  as  a 
rule,  they  are  not  carried  entirely  through  the  skin.  After  scarification, 
the  application  of  warm  aseptic  fomentations  will  maintain  the  flow  of 
blood  and  serum. 

I/eeches  are  not  used  as  frequently  as  in  former  days.  Regions 
which  contain  large  amounts  of  loose  cellular  tissue  should  not  be 
leeched.  Such  regions  are  the  prepuce,  the  labia  majora,  the  scrotum, 
and  the  eyelids.  It  is  not  wise  to  leech  the  face,  because  of  the  perma- 
nent scar  which  will  result ;  nor  should  leeching  be  carried  out  near  spe- 
cific ulcers  or  inflammations,  or  near  a  superficial  artery,  vein,  or  nerve. 
A  leech  is  never  applied  over  the  focus  of  inflammation,  but  is  placed 
between  the  inflammation  and  heart,  or  at  the  periphery  of  the  inflam- 
mation. In  epididymitis  the  leeches  are  applied  over  the  spermatic 
cord,  and  in  ocular  inflammation,  to  the  temple.  Before  applying  a 
leech,  the  part  should  be  washed,  and  shaved  if  it  is  hairy.  If  the 
leech  refuses  to  take  hold,  smear  the  part  with  milk  or  with  a  little 
blood.  Place  the  leech  upon  the  surface  under  a  glass  tube  or  an 
inverted  wine-glass.  A  leech  should  not  be  pulled  off,  but  should  be 
permitted  to  drop  off,  and  it  can  be  caused  to  drop  off  at  any  time  by 
sprinkling  it  with  salt.  After  the  leech  has  dropped  off,  if  we  desire 
the  bleeding  to  continue  for  some  time,  apply  warm  aseptic  fomenta- 
tions. If  bleeding  persists  inordinately,  it  may  be  arrested  by  the  use 
of  styptic  cotton  and  pressure.  A  Swedish  leech  will  draw  from  4  to 
6  drams  of  blood,  the  American  leech  only  about  one-half  this  quan- 
tity.    Heurteloup's  artificial  leech  is  in  reality  a  wet  cup. 

Dry  Cupping. — A  dry  cup  brings  about  local  depletion  by  draw- 

28 


434  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

ing  blood  from  the  depths  to  the  surface  of  the  body.  Of  course,  by 
the  use  of  a  dry  cup  no  blood  is  actually  abstracted.  A  cupping-glass 
is  a  small  glass  which  has  at  its  top  a  valve  and  a  stopcock.  Such  a 
glass  is  placed  upon  the  skin,  an  air-pump  is  fastened  to  it,  and  as  the 
air  is  exhausted  the  skin  bulges  into  the  cup.  When  the  air  has  been 
exhausted  to  the  required  degree,  the  stopcock  is  closed  and  the  air- 
pump  is  withdrawn,  the  cup  being  left  in  place  for  a  few  minutes. 
When  we  desire  to  remove  the  cup,  the  stopcock  is  opened,  and  the 
air  immediately  enters.  Cupping  can  be  done  in  an  emergency  by 
taking  a  tumbler,  placing  in  it  a  piece  of  paper  soaked  with  alcohol, 
lighting  this  paper,  and  inverting  the  glass  rapidly  and  placing  it  upon 
the  skin.  In  order  to  remove  such  a  glass,  press  the  finger  beneath 
the  edcre  of  the  cdass  and  raise  it  from  the  skin,  so  that  the  air  will 
enter. 

Wet  Cupping". — Before  applying  wet  cups  the  skin  should  be 
sterilized.  A  dry  cup  is  applied  to  draw  a  considerable  amount  of 
blood  to  a  part ;  the  cup  is  removed,  and  the  skin  is  cut  by  touching 
the  spring  of  a  scarificator — an  instrument  that  contains  numerous 
blades,  which  fly  out  when  the  spring  is  loosened.  After  the  employ- 
ment of  the  scarificator,  the  cup  is  again  applied,  and  is  retained  in 
place  as  long  as  the  blood  continues  to  flow.  Instead  of  applying  the 
scarificator,  a  few  incisions  may  be  made  through  the  skin  by  means 
of  a  scalpel. 

Phlebotomy  or  Venesection. — The  instruments  which  are  neces- 
sary for  this  operation  are  a  lancet  or  bistoury,  a  fillet  or  tape,  an  anti- 
septic pad,  and  a  bandage.  The  patient  sits  in  a  chair,  with  the  arm 
abducted,  extended,  and  inclined  a  little  outward.  The  surgeon  stands 
to  the  right  of  the  arm,  the  parts  are  thoroughly  asepticized,  and  the 
tape  is  tied  around  the  arm  in  order  to  make  the  veins  prominent 
(Fig.  182).  Some  surgeons  cause  the  patient  to  grasp  a  stick 
firmly  and  work  the  fingers,  in  order  to  make  the  veins  swell.  The 
puncture  can  be  made  in  either  the  median  cephalic  or  median  basilic 
vein,  the    median   basilic   being   the   one   usually   selected   (Fig.   183). 


FIG.  182. — Incisions  for  venesection  FlG.  183. — Superficial  veins  in  front 

(Bernard  and  Heuette).  of  elbow  (Bernard  and  Heuette). 

The  operator  must  be  careful  not  to  cut  completely  through  the  vein, 
because  the  brachial  artery  is  directly  beneath  it.  The  surgeon  steadies 
the  vein  with  the  thumb  and  divides  it  two-thirds  through  by  an  oblique 
cut.     The  thumb  is  removed  and  bleeding  goes  on.     When  the  patient 


INTRA  VENOUS  INJECTION. 


435 


becomes  faint,  the  fillet  is  removed,  a  pad  of  antiseptic  gauze  is  placed 
over  the  puncture,  and  a  spiral  reversed  bandage  of  the  hand  and  fore- 
arm and  a  figure-of-8  of  the  elbow  are  applied.  The  arm  is  placed  in 
a  sling  and  carried  there  for  several  days.  If  the  individual  is  extremely 
fat,  or  is  a  child  in  whom  the  veins  in  front  of  the  elbow  cannot  be 
easily  found,  venesection  may  be  practised  on  the  external  jugular 
vein.  Sometimes  bleeding  may  be  carried  out  by  opening  the  internal 
saphenous  vein. 

Intravenous  Injection  of  Saline  Fluid. — Injections  of  saline 
fluid  are  extremely  useful  in  the  treatment  of  shock,  hemorrhage, 
sepsis,  and  suppression  of  the  urine.  The  best  instrument  to  employ 
is  Colin's  apparatus  (Fig.  184).  This  consists  of  a  bell-shaped  metal 
reservoir  which  has  a  syringe  attached  to  it.  To  the  end  of  the 
syringe  is  fastened  a  rubber  tube,  which  terminates  in  a  metal 
cannula.  Between  the  reservoir  and  the  syringe  is  a  ball  valve, 
which  renders  the  passage  of  air  impossible.  When  the  reservoir 
is  filled  with  fluid,  every  time  the  piston  of  the  syringe  is  pulled 
out,  \  ounce  of  the  fluid  passes  into  the  barrel  of  the  syringe; 
and  every  time  the  piston  is  pushed  in  \  ounce  of  fluid  is  pro- 
jected from  the  cannula.  Before  using  this  instrument  it  should 
be  carefully  sterilized.  If  Colin's 
apparatus  is  not  at  hand,  a  glass 
funnel  attached  by  a  rubber  tube 
to  an  aspirating  trocar  will  make 
a  very  satisfactory  instrument.  As 
a  rule,  the  injection  is  made  into 
the  median  basilic  vein,  but  if  the 
patient  is  much  collapsed  and  the 
veins  are  small,  the  basilic  itself  is 
chosen.  A  tape  is  tied  around  the 
arm  above  the  elbow  to  make  the 
veins  prominent.  The  surface  is 
sterilized,  an  incision  is  made  over 
the  line  of  the  vein,  and  the  vessel 
is  exposed  to  the  extent  of  about 
an  inch  or  more.  A  catgut  liga- 
ture is  passed  around  the  lower  end 
of  the  exposed  portion  of  the  vein 
and  tied.  A  small  transverse  incision  is  made  in  the  middle  of  the 
exposed  portion  of  the  vein,  and  the  cannula,  filled  with  fluid,  is 
introduced  in  the  direction  of  the  heart.  A  catgut  ligature  is  passed 
around  the  portion  of  the  vein  carrying  the  cannula,  and  one  knot  is 
tied.  This  second  ligature  brings  the  vein-walls  into  close  contact  with 
the  cannula  and  prevents  leaking  (Fig.  184).  The  saline  fluid  is  slowly 
introduced.  When  a  sufficient  amount  has  been  given,  the  cannula  is 
removed,  the  second  ligature  is  tied,  the  skin-incision  is  closed  with 
sutures,  and  an  aseptic  dressing  is  applied  to  the  part. 

Hypodertnoclysis.  —  Hypodermoclysis    is    the    introduction    of 
saline  fluid  into  the  subcutaneous  cellular  tissue.      The  fluid  can  be 


Fig.  184, 


-Intravenous  injection  of  saline 
fluid  (Da  Costa). 


436  INTERNATIONAL    TEXTBOOK  OF  SURGERY. 

introduced  by  means  of  a  fountain  syringe  and  an  aspirating  trocar 
and  cannula.  After  the  skin  has  been  sterilized,  the  trocar  is  plunged 
into  the  subcutaneous  tissue  of  the  loin,  buttock,  scapular  region,  or 
submammary  region.  The  trocar  is  withdrawn,  the  cannula  being  left 
in  place.  A  fountain  syringe  has  been  previously  filled  with  hot  sterile 
salt  solution  ;  the  tube  of  this  syringe  is  attached  to  the  trocar,  and  the 
reservoir  is  hung  several  feet  above  the  level  of  the  bed.  The  fluid 
runs  in  slowly,  and  absorption  will  be  greatly  facilitated  by  occasion- 
ally rubbing  the  infiltrated  area.  After  about  a  pint  has  been  intro- 
duced, the  cannula  is  removed,  and  the  small  puncture  in  the  skin  is 
covered  with  collodion.  If  the  condition  of  the  patient  is  such  that 
more  than  a  pint  must  be  given,  the  operation  is  repeated  in  another 
region. 

Intramuscular  Injections. — These  injections  may  be  used  in 
cases  of  paralysis,  strychnin  being  the  drug  which  is  usually  employed. 
The  limb  is  placed  in  a  position  to  make  the  muscle  tense,  the  needle  is 
pushed  directly  into  the  thickness  of  the  muscle,  and  the  fluid  is  slowly 
introduced. 

Injections  of  Mercury  for  Syphilis. — Injections  may  be  made 
into  the  subcutaneous  tissue  of  the  loins,  buttocks,  or  scapular  regions 
(see  Syphilis).  Injections  may  also  be  made  into  the  veins  (Bacelli,  J. 
Ernest  Lane,  Abadie,  and  Lewin).  The  solution  used  is  a  I  per  cent, 
solution  of  cyanid  of  mercury,  20  minims  being  injected  every  day 
or  every  other  day.  A  tape  is  applied  around  the  arm  to  make  the 
veins  in  front  of  the  elbow  prominent.  The  surface  is  sterilized, 
and  the  needle  is  inserted  into  the  most  prominent  vein  and  toward 
the  heart.  The  bandage  is  removed,  the  fluid  is  slowly  injected,  and 
the  hypodermic  needle  is  withdrawn.  Digital  pressure  is  made  over 
the  puncture  for  a  few  seconds. 

Stomach-tube. — The  stomach-tube  is  employed  to  empty  the 
stomach  of  poisonous  material,  to  obtain  the  secretions  of  the  stom- 
ach for  testing,  to  introduce  food,  or  to  wash  out  the  stomach 
(lavage  or  irrigation). 

The  ordinary  stomach-tube  is  made  of  red  rubber,  and  is  about  30 
inches  long  and  -f  inch  in  diameter.  It  is  introduced  while  the  patient 
is  sitting  with  his  body  erect  and  his  head  thrown  back.  The  tube 
is  warmed  and  anointed  with  glycerin.  The  surgeon  stands  in  front 
of  the  patient,  introduces  his  left  forefinger  and  the  tube  into  the 
mouth,  and  carries  the  tube  to  the  back  of  the  pharynx  while  the 
finger  directs  it  over  the  epiglottis.  From  the  back  of  the  pharynx  it 
is  carried  gently  into  the  stomach,  the  patient  facilitating  its  passage 
by  making  attempts  to  swallow. 

If  we  desire  to  give  food  through  the  tube,  as  must  sometimes  be 
done  in  cases  of  profound  melancholia,  after  the  instrument  has  been 
passed  into  the  stomach,  a  funnel  is  placed  in  the  free  end  of  the  tube 
and  liquid  food  poured  slowly  into  the  funnel.  For  the  purpose  of 
feeding  an  insane  person  it  is  usually  preferable,  however,  to  carry  a 
small  tube  along  the  floor  of  the  nares  and  into  the  pharynx,  and  pour 


THE  RECTAL    TUBE.  437 

the  liquid  food  into  a  funnel  which  is  attached  to  the  free  end  of  the 
tube. 

In  order  to  wash  out  the  stomach  (lavage  or  irrigation),  the  tube 
should  be  60  inches  long  with  a  diameter  of  \  inch.  One-third  of  the 
tube  is  introduced  as  directed  above.  Lukewarm  water  is  poured  in 
through  the  funnel,  and  is  permitted  to  run  out  by  siphonage ;  the 
process  is  repeated  until  the  water  runs  out  clear. 

The  washing  should  be  practised  before  breakfast,  when  the  stomach 
is  empty,  except  in  those  cases  in  which  there  are  much  distention  and 
misery  at  night,  and  then  it  should  be  employed  at  night,  four  hours 
after  supper.  If  much  mucus  is  present,  a  1  per  cent,  solution  of  com- 
mon salt  or  a  3  per  cent,  solution  of  sodium  bicarbonate  should  be 
used  instead  of  lukewarm  water. 

In  cases  of  poisoning,  the  stomach  should  be  washed  out  as  above 
directed,  and  the  antidote  can  be  added  to  the  fluid  which  is  introduced. 
Some  physicians,  however,  still  prefer  to  employ  the  stomach-pump  in 
poisoning  cases. 

In  order  to  obtain  the  gastric  juice  for  examination,  the  procedure  is 
as  follows  :  The  secretion  of  gastric  juice  is  stimulated  by  introducing 
food  in  the  early  morning,  when  the  stomach  is  empty.  The  patient 
is  given  Ewald's  test-breakfast,  which  consists  of  a  dry  roll  and  f  of 
a  pint  of  tepid  water  or  very  weak  tea.  In  one  hour  the  stomach- 
tube  is  introduced.  The  stomach-tube  used  for  this  purpose  has 
an  opening  in  the  end  and  two  lateral  openings.  After  the  tube  has 
been  introduced,  the  contents  of  the  stomach  can  be  extracted  by 
the  use  of  a  syringe  or  pump,  by  the  expansion  of  a  compressed  elastic 
ball  (Mallard),  or  by  Ewald's  "  method  of  expression."  In  Ewald's 
method  the  surgeon  makes  abdominal  pressure,  or  the  patient  tries  to 
eject  the  fluid,  and  the  stomach-contents  are  forced  out  of  the  tube. 

The  Rectal  Tube. — This  tube  may  be  used  to  withdraw  gas  or  to 
introduce  fluids.  The  instrument  should  be  made  of  soft  rubber,  and 
must  be  used  very  gently.  A  hard  instrument  may  inflict  great 
damage,  and  the  forcible  use  of  any  instrument  may  be  productive  of 
harm.  In  order  to  introduce  a  rectal  tube,  the  patient  is  placed  upon 
his  left  side,  and  the  tube  is  warmed  and  anointed  with  glycerin.  The 
surgeon  introduces  the  greased  index  finger  of  his  left  hand  into  the 
rectum,  using  it  to  direct  the  tube  as  it  is  being  passed  by  means  of 
the  right  hand.  Occasionally,  the  tube  catches  in  a  mucous  fold  and 
bends  upon  itself.  If  doubling  occurs,  the  tube  should  be  withdrawn 
and  introduced  again. 

If  the  surgeon  desires  to  introduce  fluid  into  the  intestine,  the  pro- 
jecting end  of  the  tube  is  attached  by  means  of  a  large  piece  of  rubber 
tubing  to  a  fountain  syringe  or  a  reservoir  bottle,  and  fluid  is  allowed 
to  run  into  the  rectum  by  the  influence  of  gravity. 

In  order  to  treat  intussusception  by  inflation,  the  patient  is  anes- 
thetized, a  tube  is  inserted  into  the  rectum,  the  outside  of  the  tube 
around  the  anus  being  packed  with  cotton,  which  is  held  by  an  assist- 
ant. This  tube  is  connected  by  means  of  a  rubber  tube  with  a  pair  of 
bellows.  The  child  is  inverted,  and  the  bellows  are  worked  slowly 
(T.  Pickering  Pick). 


438  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

Intussusception  may  be  treated  by  hydrostatic  pressure.  The 
patient  is  prepared  as  for  inflation.  A  fountain  syringe  filled  with  warm 
normal  salt  solution  is  raised  3  feet  above  the  bed  after  being  attached 
by  means  of  a  long  tube  to  the  rectal  tube.  In  an  infant  of  less  than 
one  year  of  age,  not  over  \\  pints  can  be  introduced  with  safety.  The 
fluid  is  allowed  to  remain  in  the  intestine  for  five  or  ten  minutes  and  is 
then  permitted  to  run  out. 

In  order  to  give  an  enema,  employ  an  ordinary  fountain  syringe. 
The  nozzle  should  be  introduced  just  within  the  sphincter.  Great 
gentleness  should  be  employed,  because  injury  may  be  done  to  the 
rectum  by  a  careless  person.  It  is  better  not  to  employ  a  hard  nozzle 
at  all,  the  portion  of  the  tube  which  enters  the  rectum  being  of  soft 
rubber.  Such  a  tube  is  introduced  as  directed  above,  and  the  fluid  is 
permitted  to  flow  in  slowly.  Glycerin  can  be  injected  by  means  of  an 
ordinary  syringe. 

A  nutritive  enema  can  be  injected  into  the  rectum  by  means  of  an 
ordinary  syringe,  or  thrown  in  by  a  fountain  syringe.  A  nutritive 
enema  should  never  be  bulky ;  a  considerable  amount  of  fluid  will  be 
almost  certainly  expelled,  and  sij  is  an  amount  which  should  not  be 
exceeded. 


CHAPTER    XIV. 
ANESTHETICS   AND   SURGICAL   ANESTHESIA. 

THE  PHARMACOLOGY  OF  ANESTHETICS. 

The  differentiation  of  narcotics  into  anesthetics  and  hypnotics  is 
based  mainly  on  practical  grounds,  and  is  not  a  strict  one.  A  sub- 
stance may  be  used  in  one  case  to  abolish  the  sensation  of  pain — that 
is,  as  an  anesthetic,  and  may  serve  in  another  case  to  induce  sleep,  as 
a  hypnotic. 

Moreover,  the  anesthesia  may  be  a  general  one,  if  produced  by 
influence  on  the  central  nervous  system,  or  only  localized,  if  the  periph- 
eral sensory  nerve-endings  are  directly  acted  upon.  In  the  present 
chapter  we  shall  consider  only  briefly  the  pharmacology  of  substances 
used  in  surgery  to  produce  general  insensibility.  This  surgical  anes- 
thesia is  characterized  by  loss  of  consciousness,  loss  of  sensibility,  and 
muscular  relaxation. 

Quite  a  number  of  chemical  substances  or  their  mixtures  have  been 
tried  for  this  purpose  since  surgical  anesthesia  was  first  practically 
demonstrated  by  Morton — now  over  fifty  years  ago.  All  the  sub- 
stances which  have  been  employed  to  induce  a  more  or  less  marked 
general  anesthesia  are  volatile  at  ordinary  temperatures.  Their  vapors, 
mixed  with  air,  are  inhaled,  and  in  time  produce  in  the  subject  experi- 
mented on  the  characteristic  conditions  which  constitute  surgical  anes- 
thesia. How  are  these  effects  produced  ?  Many  hypotheses  have 
been  brought  forward  to  throw  light  upon  this  question,  but  the  true 
causation  of  anesthesia  still  remains  unknown. 

From  the  first,  anesthesia  was  thought  to.be  produced  by  an  indirect  influence  upon  the 
central  nervous  system.  Faure  believed  that  narcosis  was  due  to  stimulation  of  the  vagi, 
followed  by  cessation  of  the  pulmonary  circulation  and  coagulation  of  the  blood  in  the  pul- 
monic system.  He  believed  that  the  chloroform  did  not  enter  at  all  into  the  blood.  Dieu- 
lafoy,  Krishaber,  and  Claude  Bernard  repudiated  this  theory.  Snow  believed  that  the 
peripheral  sensory  nerves  were  made  insensible  by  chloroform,  and  that  the  central  nervous 
system  played  no  part  in  general  anesthesia.  Claude  Bernard  showed  that  the  theory  that 
narcosis  was  due  to  circulatory  changes  in  the  brain  was  incorrect.  He  proved  that  anemia 
of  the  brain  was  not  the  cause  of  narcosis,  but  only  the  sequel  of  it.  Later,  narcosis  pro- 
duced by  chemical  substances  was  thought  to  be  due  to  an  impairment  of  oxidation,  and  to 
be  more  or  less  identified  with  asphyxia.  It  was  believed  that  through  the  influence  of 
chloroform  or  other  narcotics  the  normal  oxidation-power  of  the  red  blood-corpuscles  was 
interfered  with  by  their  partial  destruction,  and  that  narcosis  was  the  result. 

Boettcher  has  shown  that  chloroform  dissolves  red  blood-corpuscles  in  the  presence  of 
atmospheric  air,  and  Bonwetch  noticed  that  oxyhemoglobin  does  not  oxidize  certain  sub- 
stances in  the  presence  of  chloroform,  which  otherwise  would  be  oxidized.  These  obser- 
vations have  been  made  only  upon  blood  outside  the  body,  never  while  circulating  in  the 
system.  If  the  red  corpuscles  were  dissolved  during  narcotization,  hemoglobinuria  would 
inevitably  be  the  sequel  ;  but  such  changes  in  the  mine  do  not  take  place.  That  the  effect 
produced  by  anesthetics  is  not  dependent  upon  changes  in  the  red  blood-corpuscles  has 
been  proven  beyond  doubt.  Lewisson  showed  that  a  frog  whose  blood  was  replaced 
by  salt  solution  can  be  narcotized  quite  as  well  as  a  normal  frog,  only  the  process  takes  a 
longer  time.      Animals  without  red  blood  are  affected  by  anesthetics  in  the  same  way  as 

439 


440  INTERNATIONAL    TEXT  BOOK   OE  SURGERY. 

those  that  have  red  blood.  Even  plants  may  be  anesthetized  (Marcet).  That  anesthesia 
produced  by  narcotics  is  not  caused  by  asphyxia  was  first  shown  by  Claude  Bernard.  He 
showed  that  cerebral  circulation  was  not  the  same  in  narcosis  as  in  asphyxia.  That  respi- 
ration is  also  different  in  the  two  cases  was  demonstrated  by  Knoll.  In  recent  years  the 
same  author,  in  collaboration  with  M.  Pick,  has  even  demonstrated  that  the  type  of  return- 
ing respiration  in  resuscitation  after  ordinary  asphyxia  differs  from  that  which  follows  stop- 
page of  respiration  in  anesthesia. 

Through  the  experimental  researches  of  Claude  Bernard,  Flourens, 
Hitzig,  Bernstein,  and  others,  it  has  been  proved,  and  is  now  generally- 
accepted,  that  narcosis  clue  to  anesthetics  is  produced  by  a  specific 
action  of  these  substances  on  the  central  nervous  system,  and  that  the 
blood,  or,  in  the  case  of  plants,  the  circulatory  nourishing  fluid,  acts 
only  as  the  carrier  of  the  anesthetic.  How  this  specific  action  on  the 
central  nervous  system  is  produced  still  remains  a  mystery. 

Claude  Bernard  thought  that  the  nerve-cells  were  reduced  under 
the  influence  of  narcotics  to  a  state  of  "  semi-coagulation  ;  "  Binz  treated 
parts  of  the  brain  directly  with  narcotics,  and  noticed  changes  in  the 
nerve-cells.  These  views  are  very  interesting,  but  they  have  not 
enlightened  us  as  to  the  real  cause  of  the  production  of  narcosis. 
Whether  this  will  ever  be  done  is  doubtful,  for  the  changes  in  the 
nerve-cells  produced  by  anesthetics  must  be  only  temporary,  or,  if  I 
may  say  so,  functional,  and  not  organic.  Otherwise  it  would  be  impos- 
sible to  understand  how  the  normal  functions  of  the  central  nervous 
system  may  be  so  quickly  restored  when  the  anesthetic  is  removed  and 
uncontaminated  air  is  inhaled.  In  short,  we  know  only  that  general 
anesthesia  is  produced  by  the  action  of  an  anesthetic  upon  the  central 
nervous  system  ;  the  process  itself  is  unknown.  To  produce  general 
anesthesia,  the  narcotic  must  be  taken  up  by  the  blood,  or,  in  the  case 
of  plants,  by  the  circulating  fluid  (Arloing).  With  animals,  the  only 
practical  way  is  by  inhalation.  Intravenous  injections,  administration 
by  the  mouth,  subcutaneous  or  intramuscular  injections,  or  rectal 
administration  (Abner  Post  and  Bull)  of  the  anesthetics  all  produce  a 
varying  amount  of  narcosis  after  the  substance  has  been  taken  into  the 
circulation ;  but  none  of  these  methods  has  any  real  advantage  over 
inhalation.  In  most  of  them  the  local  irritant  action  of  the  anesthetic 
is  generally  more  marked,  and  besides,  a  proper  regulation  of  the 
absorption  is  more  difficult.  The  local  irritant  properties  of  all  anes- 
thetics must  be  strictly  separated  from  their  general  effects.  As  a 
result  of  this  local  irritation,  increased  salivation  and  bronchial  secre- 
tion are  to  be  observed  when  an  anesthetic  is  inhaled.  Besides  this 
local  action,  a  reflex  effect  may  be  observed,  especially  in  rabbits.  As 
soon  as  such  an  animal  inhales  the  first  whiff  of  ether,  respiration  and 
circulation  cease  immediately,  to  begin  again  after  a  few  seconds.  This 
sudden  cessation  of  respiration  and  circulation  is  due  to  reflex  stimula- 
tion of  the  trigemini  and  the  superior  laryngei ;  it  does  not  occur  if 
both  trigemini  are  cut,  and  is  less  marked  when  the  laryngei  are  sev- 
ered (F.  Franck).  This  same  sudden  standstill  of  respiration  and  cir- 
culation is  said  to  occur  also  in  human  beings,  especially  with  ether, 
and  the  sudden  death  sometimes  observed  at  the  beginning  of  narcosis 
is  thus  explained.  But  this  reflex  effect  produced  by  ether  and  some 
other  narcotics  is  by  no  means  a  peculiar  property  of  these  substances, 
for  other  irritants,  such  as  ammonia,  produce  the  same  phenomenon. 


THE   PHARMACOLOGY  OF  ANESTHETICS.  44 1 

As   soon   as   the   anesthetics   have   passed  the  primary  respiratory 
channels,  they  enter  the  lungs,  are  there  absorbed  by  the  blood,  and 
by  way  of  the  left  ventricle  are   distributed  through  the  whole  body. 
It  is  only  then  that  the  general  or  constitutional  effect  of  the  narcotic 
is  produced.     The  laws  governing  the  absorption  of  anesthetics  from 
the  lungs  are  of  the  utmost  theoretical  and  practical  importance.     It  is 
to  Paul  Bert  that  we  owe  most  of  our  know  ledge  on  this  point.     From 
his  experiments  he  deduced  the  fundamental  law  that  the  absorption  of 
the  anesthetic  and  the  proportion  which  is  retained  in  the  blood  and 
system  are  dependent  on  purely  physical  facts,  other  things  being  equal 
in  the  condition  of  the  subject    narcotized.     The  intensity  of  action 
depends  on  the  partial  tension,  or  the  volume  per  cent.,  of  the  anes- 
thetic— that  is,  on  the  fixed  quantity  of  the  narcotic  contained  in  the 
inspired  air.     From  a  certain  mixture  of  an  anesthetic  the  blood  con- 
tinues to  absorb,  until  the  partial  tension  of  the  anesthetic  in  the  blood 
is  equal  to  its  partial  tension  in  the  air  inhaled.     If  inhalation  is  con- 
tinued, the  blood,  and  therefore  the  subject  under  narcosis,  cannot  take 
up  a  greater  proportion  of  the  anesthetic  than  is  contained  in  the  air 
inspired.     If  a  new  mixture  of  air  with  a  higher  partial  tension  is  now 
used,  the  blood  will  again  absorb  more  of  the  narcotic,  until  equilibrium 
is  re-established  between  the  partial  tension  of  the  gas  in  the  blood 
and  the  gas  in  the  air  of  inspiration.     Since  only  the  quantity  of  a 
poison  actually  circulating  in  the  system  acts  as  poison,  the  intensity 
of  action  of  an  anesthetic  will  depend  not  only  on  the  total  quantity 
employed,  but  on  its  partial  tension  in  the  air  inhaled.     The  quantity 
of  an  anesthetic  used  in  a  narcosis  is  therefore  no  real  indicator  of  the 
condition  of  the  subject  during  narcosis.     A  small  quantity,  if  inhaled 
in  concentrated  form — that  is,  under  a  high  partial  tension — will  act 
much  more  vigorously  than  a  larger  quantity  more  diluted  with  air. 
The    law   of   partial   tensions    guides   the  study   of  the  physiological 
effects  of  anesthetics  and  the  determination  of  the  best  possible  con- 
dition for  producing  anesthesia. 

Thus,  Spencer  found  that  animals  experimented  on  were  not  narcotized,  even  after  two 
hours,  if  the  inhaled  air  contained  only  1. 5  vol.  per  cent,  ether;  if  the  air  contained  2.5 
vol.  per  cent,  ether,  the  resulting  narcosis  was  still  incomplete.  With  3.19-3.62  vol.  per  cent, 
ether,  complete  narcosis  was  obtained  in  rabbits  and  cats  in  twenty-five  minutes.  Narcosis 
could  be  maintained  for  hours  without  any  harmful  influences  upon  respiration  or  circulation. 
Paul  Bert,  and  recently  Dreser,  had  already  used  such  graduated  mixtures  of  anesthetics 
and  air  to  produce  narcosis  in  human  subjects  with  good  results.  M.  Rosenfeld  made 
similar  experiments  with  chloroform  upon  rabbits.  He  found  that  in  using  chloroform  of 
O.96-1. 01  vol.  per  cent.,  rabbits  could  be  kept  narcotized  for  hours  without  respiratory 
stand.^till.  With  higher  percentages  standstill  occurred,  and  with  lower  percentages  nar- 
cosis was  incomplete. 

Anesthetics  are,  as  we  have  already  stated,  absorbed  from  the  lungs 
by  the  blood,  but  they  are  not  present  simply  in  solution.  At  least, 
this  is  not  the  case  with  chloroform.  Schmiedeberg  supposed  that  the 
chloroform  entered  into  a  kind  of  combination  with  certain  substances 
of  the  blood,  and  was  thus  transported  into  the  different  parts  of  the 
system.  Pohl  has  recently  demonstrated  that  the  chloroform  is  loosely 
combined  with  the  morphological  elements  of  the  blood.  He  found 
that  during  narcosis  the  red  corpuscles  contained  more  chloroform 
than  the  serum ;  but  this  combination  of  red  corpuscles  and  chloroform 


442  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

is  a  very  loose  one,  for  all  the  chloroform  may  be  separated  by  a  stream 
of  air.  The  effects  of  all  anesthetics  upon  the  circulation  are  more  or 
less  marked.  As  is  very  well  known,  chloroform  is  a  much  more  pow- 
erful depressant  than  ether.  The  effects  upon  the  circulation  are  due 
to  the  direct  action  of  the  anesthetic,  partly  upon  the  heart  and  partly 
upon  the  vessels.  The  action  upon  the  heart  consists  in  a  direct  paral- 
ysis of  the  motor  ganglia ;  as  a  sequel,  the  heart-beat  will  be  less  vig- 
orous, and,  if  the  paralysis  is  complete,  the  heart  may  come  to  a  stand- 
still even  before  respiration  stops.  Such  a  condition  may  be  observed 
both  in  human  beings  and  in  the  lower  animals. 

The  direct  influence  upon  the  heart-muscle  has  been  recently  studied  by  Dieballa  on  the 
isolated  frog's  heart.  He  compared  the  quantitative  actions  of  different  narcotics,  using 
these  substances  in  their  molecular  proportions.  He  found  in  the  main  no  qualitative  differ- 
ence in  the  action  of  the  narcotics  used.  According  to  the  concentration  of  the  narcotic,  he 
observed  a  weakening  of  the  heart's  action,  more  or  less  distinct  arhythmia  of  the  move- 
ments, and,  with  larger  doses,  a  diastolic  standstill  of  the  heart.  He  never  observed  an 
increased  action  of  the  heart  under  any  narcotic.  In  certain  stages,  especially  in  the  begin- 
ning of  narcosis,  he  found  an  increase  of  pulse-volume  ;  in  others,  the  number  of  heart- 
beats was  increased.  Either  symptom,  however,  does  not  in  itself  constitute  an  increased 
action  of  the  heart.  The  total  work  of  the  heart  done  in  a  given  time  must  be  taken  into 
consideration,  and  an  experimental  proof  that  ether  really  does  increase  the  absolute  work 
of  the  heart,  as  is  often  claimed  by  clinicians,  is  still  wanting. 

From  Dieballa's  comparative  studies  of  different  narcotics  we  learn, 
as  was  already  generally  admitted,  that  chloroform  is  the  most  power- 
ful heart-poison  of  all  the  narcotics.  The  isolated  frog's  heart  was 
brought  to  a  standstill  by  a  solution  of  chloroform  containing  0.126 
per  cent.  To  produce  the  same  effect,  ethyl  bromid  had  to  be  used  in 
12  times,  ether  in  48,  and  alcohol  in  192  times  stronger  molecular  con- 
centration. Besides  the  direct  paralyzing  effect  of  narcotics  on  the 
heart-muscle,  the  vasomotor  centers  are  also  affected.  As  a  result  of 
the  decrease  of  the  heart's  action  and  the  dilatation  of  the  arteries,  we 
see  during  narcosis  a  constant  fall  of  blood-pressure  of  an  amount  vary- 
ing with  the  substance  used.  For  chloroform  it  is  very  characteristic, 
much  less  so  for  ether. 

As  to  the  pharmacological  action  of  narcotics  upon  the  central 
nervous  system,  a  general  rule  may  be  laid  down  that  the  cerebrum  is 
first  paralyzed,  then  the  spinal  cord,  and  lastly  the  medulla  oblongata. 
It  is  characteristic  of  a  typical  narcosis,  at  least  in  animals,  that  the 
respiratory  center  is  last  paralyzed,  and  that  death  is  due  to  respira- 
tory standstill.  The  majority  of  experimenters  admit  this  general  rule. 
Clinical  experience,  however,  has  shown  us  many  cases  of  death  under 
anesthetics,  due  to  a  primary  standstill  of  the  heart ;  controversy  on 
this  point  is  still  sometimes  very  strong.  That  a  primary  standstill  of 
the  heart  may  be  the  cause  of  death  may  easily  be  explained  by  the 
direct  action  of  narcotics  upon  the  heart-muscle.  The  temperature 
falls  during  anesthesia.  This  is  mainly  caused  by  a  lessened  heat 
production  from  the  diminished  muscular  activity  and  is  partly  due  to 
an  increased  output  of  heat,  because  of  the  dilated  superficial  vessels. 

The  general  and  gradual  way  in  which  narcotics  paralyze  the  cen- 
tral nervous  system  has  been  given  above,  but  the  different  narcotics 
show  marked  individual  differences  in  their  effects.  Chloroform  and 
ether  act  more  or  less  in  the  same  way.  With  ethyl  bromid  sensation 
is  abolished  very  soon,  but  respiration  stops  almost  as  soon  as  reflexes 


SURGICAL   ANESTHESIA,    GENERAL   AXD   LOCAL.  443 

disappear.  Such  individual  differences  exist  for  pentane,  or  amylene,  as 
it  was  formerly  called,  for  methylene  chlorid,  ethylene  chloric!,  and  all 
the  other  narcotics  that  have  been  tried.  For  nitrous  oxid  it  is  charac- 
teristic that  complete  surgical  anesthesia  is  possible  under  ordinary  cir- 
cumstances only  when  atmospheric  air  is  shut  off  The  individual 
characteristics  of  each  of  the  narcotics  influence,  of  course,  its  prac- 
tical use.  Some  may  therefore  be  safely  used  in  minor  surgery,  which 
would  be  absolutely  useless,  or  even  dangerous,  for  major  operations. 

In  concluding,  the  writer  would  like  to  draw  attention  to  the  so-called 
postnarcotic  changes  produced  by  anesthetics.  By  long-continued  use 
of  chloroform,  fatty  degeneration  of  internal  organs  has  been  caused 
(Saenger,  Ungar,  Juncker,  Frankel,  etc.);  and  death  occurring  after 
successful  narcosis  and  operation  has  been  attributed  to  these  changes. 
Recently,  W.  Selbach  studied  the  after-effects  of  long-protracted  ether 
narcosis.  He  found  that  ether  could  be  regarded  as  causing  almost  no 
fatty  degeneration.  Dreser  found  after  ethyl-bromid  narcosis  a  con- 
stant excretion  of  bromin  in  the  urine  hours  after  the  subject  had 
recovered  from  the  narcosis.  He  feels  inclined  to  believe  that  ethyl 
bromid  is  persistently  retained  in  the  system  and  possibly  transformed 
into  a  more  poisonous  substance.  He  explains  thus  the  accidents 
which  may  happen  after  ethyl-bromid  narcosis  has  been  successfully 
accomplished.  Dreser's  observations  give  us  one  more  proof  of  the 
greater  toxicity  of  narcotics  containing  halogen. 

SURGICAL  ANESTHESIA,  GENERAL  AND  LOCAL. 

An  anesthetic  is  an  agent  that  abolishes  sensation.  It  may  be 
general  or  local.  The  former  affects  the  entire  system,  and  produces 
unconsciousness  ;  the  latter  affects  only  that  part  of  the  body  to  which 
it  is  directly  applied.  Anesthesia,  the  state  produced  by  an  anesthetic, 
may  be  primary  or  complete.  The  former  lasts  but  a  few  moments, 
while  the  latter  may  be  prolonged  indefinitely,  at  the  will  of  the  anes- 
thetizer.  The  conditions  of  life  or  state  of  health,  as  regards  age, 
injury,  or  disease,  are  few  in  which  a  judicious  use  of  anesthetics  may 
not  safely  be  resorted  to  with  benefit  in  case  of  necessity. 

General  Anesthesia. — General  surgical  anesthesia  was  demon- 
strated in  public  for  the  first  time,  and  thus  became  an  established, 
practical  fact,  at  the  Massachusetts  General  Hospital  on  Friday, 
October  16,  1846.  The  drug  used  upon  that  occasion  was  sulphuric 
ether.  The  administrator  was  William  T.  G.  Morton.  The  operator 
was  John  C.  Warren.  The  operation  was  the  removal  of  a  vascu- 
lar tumor  from  the  neck.  It  is  a  singular  fact  that  during  half  a 
century's  experience  with  anesthetics  no  safer  or  better  agent  for 
general  use  has  been  discovered ;  and  furthermore,  that  the  method  of 
administration  by  means  of  the  cone  adopted  in  the  early  days  of 
anesthesia  is  still  in  very  general  use,  and  is  perhaps  more  commonly 
employed  than  any  other  special  method. 

The  principal  general  anesthetics  are  ether,  chloroform,  and  nitrous 
oxid  gas.  Various  mixtures  and  combinations  of  these  agents  with 
each  other,  with  alcohol,  and  with  other  substances  have  been,  from 
time  to   time,   suggested.      Bichlorid   of  methylene,  bromid  of  ethyl, 


444  INTERNATIONAL    TEXT-BOOK'   OF  SURG ER Y. 

pental,  and  other  drugs  have  been  employed,  but  none  of  them  has 
gained  the  confidence  of  any  considerable  proportion  of  the  profession. 
The  two  principal  anesthetics  the  world  over  are  ether  and  chloroform. 
The  former  is  in  general  use  in  the  northern,  middle,  and  western  parts 
of  this  country,  while  in  the  southern  portion  and  in  most  foreign  coun- 
tries chloroform  is  the  favorite.  The  fact  that  ether  is  the  safer  of  the 
two  agents  is  everywhere  slowly  but  surely  being  recognized,  and  as  a 
result,  its  use  is  becoming  more  general  than  heretofore.  Bichlorid  of 
methylene  was  used  to  some  extent  in  England  at  one  time,  especially 
by  Spencer  Wells.  The  agent  used  by  him  under  this  name  was  com- 
posed of  4  parts  of  chloroform  and  i  part  of  methylic  alcohol.  The 
effects  were  practically  the  same  as  those  of  chloroform,  even  including 
the  fatalities.  Various  compounds,  such  as  mixtures  of  chloroform  and 
ether,  have  been  sold  under  that  name,  while  the  genuine  chemical, 
bichlorid  of  methylene  (C2H2CI2),  is  devoid  of  anesthetic  properties. 
For  these  reasons  alone,  this  agent  may  very  properly  be  considered  as 
being  unworthy  of  further  attention.  Bromid  of  ethyl  (not  ethylene, 
which  is  a  very  dangerous  agent)  resembles  nitrous  oxid  in  the  prompt- 
ness with  which  the  patient  passes  under  and  out  of  its  influence.  The 
effect  of  the  drug  disappears  in  a  few  moments  after  the  inhalation  is 
stopped,  leaving  the  subject  in  his  usual  condition.  From  the  fact  that 
several  deaths  have  occurred  from  its  use,  and  also  that  it  is  rather 
unstable,  being  changed  by  exposure  to  light  and  air  to  a  dangerous 
compound,  this  agent  will  never  supplant  the  older  and  more  reliable 
anesthetics. 

Various  anesthetic  mixtures  have  been,  and  are  now,  used  to  a 
limited  extent  all  over  the  world.  The  most  common  one  is  the 
A.  C.  E.,  or  "  Ace  of  Spades  "  mixture.  It  is  composed  of  alcohol, 
I  part ;  chloroform,  2  parts ;  and  ether,  3  parts,  by  measure.  The 
"  Vienna  mixture "  is  composed  of  1  part  chloroform  and  6  parts 
ether.  The  use  of  the  various  mixtures  of  anesthetic  agents  has  never 
met  with  the  approval  of  any  considerable  proportion  of  the  profession, 
for  the  reason  that  their  advantages  over  the  single  drugs  are  not  suf- 
ficiently pronounced  and  decisive  to  lead  to  their  adoption. 

Sulphuric  ether,  the  safest  and  best  anesthetic  yet  discovered  for 
ordinary  surgical  work,  is  made  from  sulphuric  acid  and  alcohol.  Ab- 
solute ether  has  a  specific  gravity  of  .718  at  a  temperature  of  590  F., 
while  that  used  for  anesthetic  purposes  has  a  specific  gravity  of  .725 
at  the  same  temperature.  It  is  clear,  colorless,  and  very  volatile ; 
it  has  a  pungent  odor,  and  should  leave  no  residue  whatever  upon 
evaporation.  Ether  should  remain  clear  on  adding  a  little  oil  of 
copaiba.  This  drug  is  best  kept  securely  corked  in  tin,  and  in  a  cool, 
dark  place.  The  vapor  is  more  than  two  and  a  half  times  as  heavy  as 
atmospheric  air  (sp.  gr.  2.58),  while  that  of  chloroform  is  a  little  more 
than  four  times  as  heavy.  The  fact  should  be  constantly  borne  in  mind 
that,  owing  to  the  inflammable  nature  of  ether  and  its  rapid  vaporiza- 
tion, much  the  larger  proportion  of  the  vapor  falls  rather  than  rises. 
The  slight  amount  of  danger  to  be  apprehended  from  the  ignition  of 
ether  is  shown  by  the  fact  that  for  more  than  thirty  years  the  night 
surgery  at  the  Boston  City  Hospital  has  been  done  under  a  six-light 
chandelier  not  over  3  feet  above  the  patient's  head,  and  no  accident  of 


SURGICAL   AXESTHESIA,    GENERAL   AND   LOCAL.  445 

this  sort  has  ever  occurred  in  consequence.  Accidents  from  ignition 
of  ether  are  rare,  easily  prevented,  and  should  not  militate  in  the  least 
degree  against  its  use. 

Circumstances  permitting,  there  are  certain  precautions  to  be  taken 
before  giving  ether.  The  stomach  should  be  empty,  to  avoid  vomiting 
in  the  early  stages  of  anesthesia.  For  this  reason  it  is  well  for  the 
patient  to  abstain  from  all  solid  food  and  from  milk  for  at  least  six  hours 
previously.  A  little  bouillon,  clear  soup,  or  coffee  may  be  taken  a  couple 
of  hours  before  the  inhalation  ;  and  in  weak  or  exhausted  people  a  little 
stimulant  should  be  given  by  mouth  or  rectum  shortly  before  the  anes- 
thetic. Another  excellent  plan  in  such  cases  is  to  give  from  TV  to  \ 
gr.  (gm.  .005-008)  of  morphin  sulphate  under  the  skin,  just  prior  to 
the  ether.  It  steadies  the  nervous  system,  fortifies  the  anesthetic,  and 
controls  the  pain  to  a  certain  extent  when  the  effects  of  the  ether  pass 
away,  thereby  in  some  instances  preventing  the  vomiting,  a  reflex 
symptom  depending  oftentimes  upon  the  pain.  The  bowels  and  blad- 
der should  also  be  emptied,  the  former  by  means  of  an  enema,  and  the 
latter  by  a  catheter,  if  necessary.  The  patient  should  be  dressed 
warmly  and  loosely  about  the  neck  and  waist,  to  allow  of  free  circu- 
lation and  respiration.  Great  care  should  be  taken  throughout  the 
period  of  unconsciousness  to  preserve  the  patient's  body-heat,  as  this 
is  one  of  the  principal  factors  in  the  prevention  of  shock.  Whatever 
anesthetic  is  selected,  it  should  always  be  given  in  the  presence  of  a 
third  person,  in  order  that  the  anesthetist  may  thereby  receive  any 
assistance  necessary,  and  also  that  no  unjust  accusation  may  be 
brought  against  him  afterward  by  female  patients.  Neglect  of  this 
rule  has  brought  unmerited  disgrace  upon  more  than  one  innocent 
man  in  the  past,  by  reason  of  erotic  delusions,  which  are  occasionally 
present  under  the  narcotic.1  It  is  his  duty  to  thus  protect  himself,  as 
well  as  the  patient  and  her  friends. 

Mode  of  Administration. — A  great  many  different  inhalers  for  giving 
ether  have  been  devised  from  time  to  time,  but,  aside  from  economy  in 
the  amount  of  the  drug  consumed,  they  are  of  comparatively  little  use. 
Good  judgment  and  a  thorough  knowledge  of  the  process,  derived 
from  a  proper  training  and  experience,  are  the  principal  requisites  of  a 
good  etherizer,  and  no  form  of  apparatus  yet  devised  can  take  the  place 
of  these  attributes.  As  a  rule,  more  skill  and  care  are  required  in  the 
use  of  the  inhalers  than  in  that  of  the  cone  and  its  modifications.  The 
closed  inhalers  are  pernicious  from  the  fact  that  the  air  is  breathed  over 
and  over  again,  becomes  loaded  with  carbonic  acid,  and,  at  times,  is  apt 
to  be  too  heavily  charged  with  the  narcotic,  thereby  producing  cyanosis 
and  other  unfavorable  symptoms.  While  these  objections  are  less 
applicable  to  the  open  inhalers,  yet  both  kinds  are  often  so  compli- 
cated or  inefficient,  without  compensating  advantages,  that  they  have 
not  received  the  general  approval  of  the  profession. 

Special  inhalers  naturally  find  their  chief  field  of  usefulness  in  hos- 
pitals, where   large   amounts  of  ether  are   consumed.2     With  a  good 

1  A  dentist  in  England  was  accused  by  a  woman  of  criminal  assault  while  she  was  under 
the  influence  of  chloroform,  although  her  father,  mother,  a  physician,  and  the  dentist's  assist- 
ant  were  present  during  the  entire  period  of  narcosis  (Turnbull,  Artificial  Anesthesia,  p.  524). 

-  The  cost,  at  wholesale  price,  of  the  ether  used  at  the  Boston  City  Hospital  in  1896 
was  about  S2300. 


446  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

inhaler  a  skilful  etherizer  can  save  from  30  to  50  per  cent,  in  the 
amount  of  drug  required  to  accomplish  the  same  work,  as  compared 
with  the  ordinary  cone. 

Of  the  numerous  inhalers  which  have  been  brought  out  from  time  to  time,  mention  may 
be  made  of  Clover's,  Ormsby's,  and  Leute's  as  examples  of  the  closed  varieties,  and  of  Ail  is' s 
and  Blake's  as  types  of  the  open  kind.  The  latter  open  inhaler,  now  in  use  at  the  Boston 
City  Hospital,  is  satisfactory  from  the  fact  that  it  is  simple,  cheap,  easily  used  and  cleansed, 
and  accomplishes  all  that  can  reasonably  be  expected  of  any  inhaler.  It  is  a  truncated, 
somewhat  flattened  tin  cone,  with  an  inflated  rubber  rim,  and  a  wire  frame  inside,  about 
which  is  wrapped  a  little  ordinary  gauze  to  hold  the  ether.  This  cone  is  readily  cleansed  by 
simply  running  hot  water  through  it  and  putting  in  fresh  gauze.  With  this  apparatus  a 
careful  and  skilful  anesthetizer  need  not  use  over  half  the  amount  of  ether  that  he  would 
with  the  ordinary  napkin  cone. 

From  the  earliest  days  of  modern  anesthesia,  the  most  common 
method  of  administering  ether  has  been  upon  a  towel  folded  in  the 
shape  of  a  bowl,  and  stiffened  with  paper  placed  between  the  two  outer 
layers,  which  also  serve  partially  to  confine  the  vapor.  The  straw  cuff 
of  the  marketman  is  objectionable  from  the  fact  that  it  cannot  be  kept 
clean  and  fresh,  which  is  of  the  greatest  importance  in  the  avoidance 
of  "  inhalation  pneumonia."  Every  patient  should  take  his  anesthetic, 
whatever  it  may  be,  from  a  thoroughly  clean  and  fresh  inhaler,  as  no 
other  is  either  safe  or  decent.  The  principal  objection  to  the  napkin 
is  the  unnecessary  amount  of  ether  wasted.  This  is  best  obviated  by 
having  the  sides  of  the  inhaler  made  of  an  impervious  material,  such  as 
tin,  while  the  opening  at  the  top  should  be  sufficiently  large  to  allow 
a  free  ingress  of  air.  There  should  be  a  generous  air-space — 50  to  60 
cubic  inches — about  the  mouth,  in  order  that  the  patient  may  be  spared 
the  sensation  of  insufficient  room  for  breathing.  A  free  and  easy  cir- 
culation of  air  through  the  inhaler,  whatever  its  shape  or  kind,  is  indis- 
pensable to  a  satisfactory  apparatus.  Pure  air  charged  with  ether- 
vapor,  in  the  proper  proportion — best  estimated  by  its  effects  upon  the 
patient — is  the  most  desirable  mixture  for  safe  and  efficient  anesthesia. 

The  patient,  warmly  and  loosely  clothed,  should  lie  in  an  easy 
position  upon  his  back,  with  his  head  moderately  raised.  False  teeth, 
tobacco,  gum,  and  any  other  foreign  substance  should  be  removed 
.from  his  mouth.  A  basin,  gag,  tongue-forceps,  and  towels  should  be 
at  hand,  and  all  preparations  for  the  operation,  or  whatever  is  to  be 
done,  should  be  made  out  of  the  patient's  sight  and  hearing.  Every- 
thing in  his  room  should  be  done  quietly,  without  excitement  or  con- 
fusion. He  is  to  be  assured  that  although  the  vapor  is  not  pleasant, 
yet  it  is  perfectly  safe  ;  that  plenty  of  time  will  be  given  him ;  that  he 
shall  not  be  hurried,  and  that  nothing  will  be  done  until  he  is  sound 
asleep.  There  should  be  no  whispering  nor  unnecessary  talking  while 
the  patient  is  conscious,  as  they  distract  his  attention  as  well  as  that  of 
the  etherizer.  He  is  to  be  instructed  not  to  resist,  but  to  resign  him- 
self readily  to  the  influence  of  the  drug,  to  close  his  eyes,  and  to  breathe 
naturally  through  the  nose  or  mouth,  as  is  most  agreeable  to  himself. 

At  first,  the  inhaler  should  be  held  about  a  foot  from  the  face,  and 
gradually  brought  nearer,  as  the  patient  becomes  accustomed  to  the 
vapor.  The  cardinal  rule  to  be  observed  in  administering  ether  is  never 
to  give  it  in  such  concentration  as  to  interfere  with  natural  respiration 
or  cause  coughing,  choking,  or  holding  of  the  breath.     All  of  these 


SURGICAL    ANESTHESIA,    GENERAL    AND    LOCAL.  447 

symptoms  rapidly  disappear  upon  allowing  a  few  breaths  of  fresh  air. 
The  inhaler,  after  being  replenished  with  ether,  should  not  be  placed  as 
close  to  the  face  as  before,  but  gradually  returned  to  its  former  position, 
thereby  avoiding  the  overwhelming  effects  of  the  vapor,  as  indicated  by 
coughing  and  efforts  to  get  away  from  it.  The  natural  regular  respi- 
ration affords  the  best  means  of  saturating  the  system  with  the  anes- 
thetic, and  its  employment  is  attended  with  the  least  unpleasant  effects. 
The  custom  of  constantly  nagging  or  urging  the  patient  to  breathe 
deeper  or  faster  is  not  always  judicious.  It  would  be  well  for  every 
physician  to  inhale  ether  once  to  the  point  of  unconsciousness,  in  order 
that  he  might  fully  appreciate  the  importance  of  giving  the  drug  care- 
full}'  and  slowly.  The  dreadful  sensation  of  suffocation,  which  in  the 
vast  majority  of  cases  is  avoidable,  leaves  upon  the  patient's  mind  a 
lasting  antipathy  to  the  agent. 

Except  in  the  case  of  very  young  children,  hasty  or  forced  etheri- 
zation in  the  early  stages  is  unnecessary  and  cruel,  and  may  be  harm- 
ful. Too  sudden  application  of  the  vapor  irritates  the  mucous  mem- 
brane of  the  air-passages,  excites  spasm  of  the  laryngeal  and  respiratory 
muscles,  and  closes  the  glottis,  thereby  inducing  the  horrible  sensation 
of  suffocation.  The  patient  naturally  struggles  for  fresh  air  according 
to  his  strength,  and  more  or  less  brute  force  is  required  to  restrain  him 
within  bounds.  Aside  from  the  alcoholic,  the  hysterical,  and  the 
extremely  nervous  people,  these  unpleasant  manifestations  are  entirely 
unnecessary  and  avoidable.  The  great  majority  of  patients  can  be  put 
under  the  influence  of  ether  in  from  ten  to  twenty  minutes  with  little 
or  no  restraint,  and  without  undergoing  the  disagreeable  experience  of 
impending  suffocation.  Patience,  good  judgment,  proper  training,  and 
experience  are  the  chief  requisites  of  an  efficient  etherizer. 

The  indications  of  complete  anesthesia  are  stertorous  respiration, 
muscular  relaxation,  as  shown  by  moving  the  arms  without  provoking 
resistance,  and  absence  of  corneal  reflex.  The  latter  test  should  be 
resorted  to  as  little  as  possible,  as  a  troublesome  conjunctivitis  occa- 
sionally follows  its  abuse. 

The  primary  object  of  anesthesia  being  the  prevention  of  pain,  com- 
plete muscular  relaxation  is  in  many  cases  unnecessary.  The  patient 
knows  nothing  and  feels  nothing,  and  for  these  reasons  many  opera- 
tions can  be  well  done  without  his  being  etherized  to  the  point  of 
absence  of  all  reflex  muscular  movement.  In  the  reduction  of  dislo- 
cations and  in  various  other  manipulations,  more  or  less  complete 
relaxation  of  the  muscles  is  essential ;  but  in  many  operations,  there 
can  be  no  doubt,  more  ether  is  given  than  is  really  necessary,  thereby 
needlessly  prolonging  the  narcosis,  increasing  the  unpleasant  after- 
effects, and  often  adding  to  the  shock  and  prostration.  One  of  the 
principal  objections  to  the  use  of  any  anesthetic  is  the  fact  that  the 
operator  may  thereby  be  led  to  ignore  the  flight  of  time,  to  the  detri- 
ment of  the  patient.  It  is  true,  in  a  general  way,  that  the  shorter  the 
duration  of  an  operation  and  the  smaller  the  amount  of  ether  given 
the  better.  Ether  is  primarily  a  stimulant,  but  after  a  time,  varying 
greatly  in  different  people,  as  regards  age,  natural  vigor,  present  con- 
dition, and  so  on,  it  ceases  to  act  in  this  manner,  and  if  carried  too  far 
may  aid  in  producing  exhaustion  or  even  collapse.     The   respiration 


448  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

then  becomes  shallow  and  sighing,  the  skin  cyanotic  and  bathed  with 
profuse  sweat,  the  pulse  weak  and  irregular,  and  the  patient  is  reduced 
to  a  state  of  great  danger.  To  avoid  this  unfortunate  condition  of 
affairs,  so  far  as  the  anesthetic  is  concerned,  it  is  better  frequently  to 
interrupt  its  administration  by  giving  fresh  air,  and  allow  the  patient  to 
rally  partially  from  the  effect  of  the  drug.  A  few  whiffs  of  ether  now 
and  again  will  keep  him  free  from  pain,  anxiety,  and  fright.  As  he 
knows  little  or  nothing,  a  moderate  amount  of  involuntary  struggling 
unattended  with  suffering  does  no  harm,  while  the  danger  of  prostra- 
tion and  collapse  will  be  reduced  to  a  minimum.  With  suitable  pre- 
cautions, capital  operations  upon  very  frail  and  exhausted  patients  can 
frequently  be  done  successfully  in  the  following  manner :  All  prepara- 
tions having  been  made,  the  patient  is  carefully  etherized,  and  the 
operation — an  amputation,  for  example — is  quickly  done.  The  ether  is 
removed  when  the  bone  has  been  divided,  and  while  the  vessels  are 
being  secured  and  the  wound  closed  a  few  whiffs  of  the  anesthetic  are 
given  occasionally.  The  result  is  that  by  the  time  the  dressings  are 
completed,  the  patient  has  nearly  recovered  from  the  narcotic,  and  is 
free  from  the  symptoms  of  alarming  prostration  that  so  frequently 
follow  the  same  operation  when  unduly  prolonged.  The  smaller  the 
quantity  of  ether  given  in  severe  or  prolonged  operations,  compatible 
with  the  objects  to  be  attained,  the  better  for  the  patient.  This  matter 
is  of  a  good  deal  of  importance,  and  does  not  always  receive  the  atten- 
tion it  deserves.  The  patient  once  having  been  etherized,  the  rule  to  be 
borne  in  mind  is  the  saving  of  time,  blood,  animal  heat,  and  anesthetics. 
While  recovering  from  the  influence  of  any  anesthetic,  no  person 
should  be  left  alone  for  a  moment,  until  he  is  conscious  of  his  condi- 
tion. This  rule  is  of  special  importance  in  the  care  of  the  very  old 
and  feeble,  of  the  very  young,  and  of  those  who  have  undergone  a 
severe  or  prolonged  operation.  Accidents  from  vomiting  and  choking 
are  possible,  but  more  important  is  the  danger  of  sudden  collapse, 
which  calls  for  prompt  measures  for  relief.  Upon  the  appearance  of 
symptoms  suggesting  this  condition,  the  patient  should  be  well  covered, 
and  surrounded  with  warm,  but  not  hot,  bottles.  The  foot  of  the  bed 
or  table  should  be  raised  about  a  foot ;  stimulants,  such  as  brandy  and 
coffee,  should  be  given  per  rectum,  as  the  stomach  acts  slowly,  if  at  all, 
while  the  patient  is  in  this  condition.  Strychnin,  atropin,  morphin,  or 
digitalis,  with  or  without  brandy  or  "  cologne  spirit,"  which  is  of  nearly 
the  same  strength  as  absolute  alcohol,  should  be  given  under  the  skin. 
The  room  should  be  darkened,  quiet  enjoined,  and  sleep  encouraged. 
These  measures  will  usually  suffice  to  rally  the  patient  from  danger 
and  put  him  on  the  way  to  recovery. 

Rectal  Etherization. — It  was  thought  at  one  time  that  rectal  etherization  might  prove 
feasible  in  operations  about  the  face  and  throat.  It  was  soon  found,  however,  to  be  difficult 
or  impossible  to  regulate  the  dose  satisfactorily.  The  narcosis  might  be  too  profound  or  too 
prolonged,  the  bowels  become  distended,  and  the  mucous  membranes  so  irritated  as  to  give 
rise  to  tenesmus  and  bloody  stools.  For  these  reasons  the  method  has  never  found  favor 
with  the  profession. 

A  very  good  method  of  continuing  the  etherization  in  operations 
about  the  mouth  and  face  is  to  force  the  vapor  through  the  nose 
by  means  of  a   tube  and  bulb.     The  apparatus  devised  by  Souchon 


SURGICAL    AXESTHESIA,    GENERAL   AND   LOCAL.  449 

of  New  Orleans  is  a  good  one  for  this  purpose.  The  patient  is  first 
etherized  in  the  usual  manner;  then  the  tube  having  been  passed 
through  one  nostril  into  the  pharynx,  the  air  is  pumped  through  the 
ether  in  sufficient  quantities  to  keep  up  the  proper  degree  of  narcosis. 
In  operations  attended  by  danger  of  suffocation  from  blood  trickling 
down  the  throat,  it  is  better  and  safer  first  to  perform  tracheotomy, 
then  plug  the  pharynx,  and  continue  the  etherization  through  the 
tracheal  tube.  All  danger  from  strangulation  is  thus  avoided.  Nitrous 
oxid  given  as  a  preliminary  to  ether  is  a  favorite  agent  with  many  sur- 
geons, and  is  used  to  a  considerable  extent  both  in  hospitals  and  in 
private  practice.  Except  in  alcoholics  and  in  hysterical  and  very 
nervous  people,  anesthesia  is  more  quickly  and  pleasantly  produced  by 
this  method  than  with  ether  alone.1 

Certain  unpleasant  or  even  serious  events  may  occur  to  the  patient 
in  taking  ether,  which  will  now  receive  consideration.  The  inflammable 
nature  of  the  drug  and  the  precautions  necessary  to  be  taken  in  con- 
sequence have  already  received  attention. 

Should  ether  be  given  upon  a  full  stomach,  the  respiration  may  not 
become  free  and  regular  until  vomiting  has  taken  place,  after  which  no 
further  trouble  need  be  expected  from  that  source.  No  danger  is  to 
be  apprehended  from  vomiting  during  or  after  etherization,  except  the 
danger  of  undigested  food  being  drawn  into  the  trachea.  This  accident 
has  happened  and  has  caused  death,  but  it  is  one  of  the  rarest  of  fatali- 
ties, and  is  probably  as  common  without  as  with  an  anesthetic.  The 
treatment  is  an  immediate  tracheotomy,  provided  the  offending  mate- 
rials are  not  at  once  ejected  by  the  natural  efforts  of  the  patient. 
While  vomiting,  the  patient  should  be  turned  upon  his  side,  the  mouth 
opened,  and  close  watch  kept  of  the  respiration  and  color  to  see  that 
the  larynx  and  trachea  are  free.  It  is  believed  by  good  authorities 
that  -j^q  to  y^-q  grain  of  atropin  sulphate,  given  under  the  skin  a 
short  time  before  ether,  lessens  the  subsequent  nausea  and  vomiting 
very  materially.  It  is  to  be  remembered  that  the  air-passages  of  old 
people  are  much  less  sensitive  to  the  presence  of  blood,  mucus,  and  all 
foreign  substances  than  are  those  of  the  ordinary  adult,  and  hence 
that  they  require  special  attention  in  this  regard  while  under  the  influ- 
ence of  anesthetics. 

The  administration  of  oxygen  immediately  after  the  removal  of  the 
ether  is  a  favorite  practice  with  many  physicians,  who  claim  that  the 
period  of  recovery  from  the  anesthetic  is  thereby  shortened,  and  also 
that  the  nausea  and  vomiting  are  much  diminished.  It  is  given  from 
a  flask,  different  sizes  of  which  are  in  the  market.  From  ten  to  fifteen 
minutes  is  usually  a  sufficient  time  for  its  exhibition,  and  about  25 
gallons  of  the  gas  are  consumed.  It  is  conducted  through  a  bottle 
of  water  and  directed  upon  the  face  of  the  patient  until  he  has  fairly 
recovered  from  the  ether. 

Another  occasional  complication  in  giving  ether  is  the  free  secre- 
tion of  mucus.  This  occasionally  results  in  edema  of  the  lungs,  and 
threatens  suffocation.  It  is  most  often  seen  in  fat  and  elderly  patients 
inclined  to  chronic  bronchitis  or  asthma,  or  in  those  having  a  weak 
heart,  or  suffering  from  exhaustion,  as  from  a  strangulated  hernia  of 

1  See  page  460. 
29 


450  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

long  duration.  These  patients  can  usually  take  ether  with  safety,  if 
due  care  is  exercised  to  avoid  giving  too  much.  They  are  to  be 
kept  just  on  the  verge  of  complete  anesthesia,  and  allowed  plenty  of 
pure  air.  A  hypodermic  injection  of  atropin  sulphate,  y^  to  y^ 
grain  given  an  hour  before  the  ether,  would  not  only  tend  to  check 
this  over-secretion  of  mucus,  but  also  act  as  a  desirable  stimulant 
to  the  respiratory  center.  The  action  of  chloroform  in  these  cases 
is  more  satisfactory  than  ether.  The  treatment  of  this  complication 
consists  in  removing  the  ether,  opening  the  windows,  fanning,  and 
artificial  respiration,  great  care  being  taken  to  insure  a  free  passage 
of  air  into  the  lungs.  On  re-establishing  the  respiration,  the  cyanosis 
will  quickly  disappear,  and  the  patient  is  safe.  Should  the  heart  show 
signs  of  failing,  -^  to  -£$  grain  of  strychnin  sulphate  should  be  given 
under  the  skin.     Stimulants  may  also  be  given  in  the  same  manner. 

Temporary  interference  with  breathing  during  the  later  and  deeper 
stages  of  ether  narcosis,  due  to  relaxation  of  the  muscles  of  the  throat 
and  closure  of  the  glottis  from  falling  back  of  the  tongue  and  epiglottis, 
is  not  infrequent.  Although  violent  efforts  on  the  part  of  the  diaphragm 
continue  to  be  made,  yet  the  cyanosis  and  deep  congestion  of  the  face 
plainly  indicate  that  no  air  enters  the  lungs.  This  state  of  affairs  is  not 
at  all  alarming  or  serious,  provided  proper  measures  be  taken  for  relief. 
They  consist  in  opening  the  mouth  and  drawing  forward  the  tongue  in 
such  a  manner  as  to  raise  its  base,  and  with  it  the  epiglottis,  thereby 
allowing  the  air  to  enter  the  lungs.  With  an  efficient  gag  between  the 
teeth,  the  tongue  may  be  drawn  out  with  forceps,  care  being  taken  to 
'avoid  undue  violence  to  that  organ.  Its  base  is  thereby  raised,  and 
with  it  the  epiglottis,  allowing  a  free  ingress  of  air.  Another  method 
of  accomplishing  the  same  object  is  simply  to  flex  the  head  upon  the 
chest,  and  by  the  action  of  the  styloid,  and  probably  other  muscles,  to 
open  the  glottis.  Pressing  the  lower  jaw  forward,  partially  dislocating 
it  upon  the  articular  eminences,  is  also  another  favorite  method  of 
securing  a  free  passage  of  air  through  the  larynx.  Too  forcible  or 
persistent  pressure  behind  the  angles  of  the  lower  jaw  may  not  only 
leave  an  uncomfortable  soreness,  but  might  possibly  lead  to  inflamma- 
tion of  the  parotid. 

A  tetanic  spasm  of  the  respiratory  muscles  occasionally  occurs,  but 
is  overcome  readily  by  removing  the  ether,  opening  the  glottis,  fanning 
the  patient,  and  in  extreme  cases,  by  resorting  to  artificial  respiration. 
This  is  a  somewhat  rare  complication. 

It  is  seldom,  indeed,  that  tracheotomy  is  required  for  any  acci- 
dent due  to  the  ether  alone.  The  operation  may  be  necessary  for 
edema  or  spasm  of  the  glottis,  a  complication  which  is  liable  to  appear 
in  croup,  deep  cellulitis  of  the  neck,  tumors  pressing  upon  the  trachea 
or  laryngeal  nerves,  etc.  A  more  common  danger  is  the  escape  of 
blood  into  the  air-passages  during  operations  about  the  mouth,  nose, 
and  throat.  This  may  occur  very  insidiously,  and  the  first  warning 
given  may  be  cessation  of  breathing.  The  blunted  sensibility  of  the 
air-passages  may  have  prevented  any  warning  cough  or  choking,  a 
condition  peculiar  to  elderly  or  very  weak  and  exhausted  persons. 
This  event  calls  for  prompt  and  energetic  treatment.  The  trachea  is 
to  be  opened  at  once,  an  elastic  catheter  carried  down  into  the  bronchi, 


SURGICAL   ANESTHESIA,    GENERAL   AND   LOCAL.  45 1 

and  air  forced  into  the  lungs,  for  the  purpose  of  driving  out  the  blood. 
Suction  does  no  good.  Nature  does  not  clear  the  bronchial  tubes  in 
this  manner,  neither  can  the  surgeon.  Artificial  respiration  and  hypo- 
dermic stimulation  may  also  be  necessary  to  revive  the  patient.  This 
accident  is  not  peculiar  to  ether  any  more  than  to  any  other  anesthetic, 
but  the  possibility  of  its  occurrence  should  be  recognized,  and  proper 
measures  taken  to  meet  it  promptly  and  efficiently. 

While  no  known  anesthetic  is  entirely  safe  under  all  circumstances, 
yet  the  experience  of  half  a  century  proves  most  conclusively  that  sul- 
phuric ether  is  the  safest  one  hitherto  discovered.  Upwards  of  65,000 
persons  have  been  etherized  at  the  Massachusetts  General  Hospital 
and  at  the  Boston  City  Hospital,  and,  so  far  as  can  be  ascertained, 
there  has  not  been  a  single  death  due  solely  to  the  anesthetic.  Patients 
occasionally  die  while  under  the  influence  of  ether,  but  there  are  always 
contributory  causes,  such  as  debility,  shock,  uremia,  hemorrhage,  etc. 
Pure  anhydrous  sulphuric  ether  carefully  given  to  healthy  persons 
seldom,  if  ever,  results  fatally.  It  is  the  rarest  of  accidents,  and  the 
practitioners  are  few  who  have  ever  seen  such  a  termination. 

Chloroform  causes  death  in  ratio  of  about  1  to  2000  cases.  The 
aggregate  is  large,  however,  by  reason  of  the  great  numbers  to  whom 
the  drug  is  given.  There  were  96  published  deaths  from  chloroform 
in  England  in  1897,  and  no  one  can  tell  how  many  deaths  from  this 
cause  were  not  published.1 

A  healthy  person  inhales  chloroform  for  the  purpose  of  having  a 
minor  operation  done  which  in  itself  is  free  from  danger,  such  as  the 
extraction  of  a  tooth,  the  incision  of  an  abscess,  etc.  Before  anesthesia 
is  complete,  and  before  any  operation  is  done,  the  heart,  with  little  or 
no  warning,  suddenly  stops,  and  the  patient  is  dead.  All  efforts  at 
resuscitation  are  in  vain.  An  autopsy  reveals  no  adequate  cause  of 
death  aside  from  the  anesthetic. 

About  40  per  cent,  of  the  fatalities  from  chloroform  occur  under 
circumstances  and  in  a  manner  similar  to  those  above  narrated.  The 
unfortunate  result  cannot  be  ascribed  to  the  quantity  or  quality  of  the 
drug  nor  to  the  mode  of  administration,  as  it  has  occurred  in  the  prac- 
tice of  some  of  the  most  experienced  men  in  the  profession.  Very  prob- 
ably it  is  due  to  some  inherent  quality  of  the  drug  itself,  coupled,  per- 
haps, with  some  idiosyncrasy  on  the  part  of  the  patient,  which  no  one 
can  foresee.  This  occasional  fatally  treacherous  action  of  chloroform 
is  the  main  objection  to  its  use  as  an  ordinary  anesthetic. 

The  danger  to  be  apprehended  from  chloroform  is  cardiac  paralysis 
— syncope — while  that  from  ether  is  ordinary  asphyxia.  The  former  is 
sudden  in  its  onset  and  too  often  not  remediable  ;  the  latter  is  gradual 
in  its  appearance  and  readily  avoided  or  corrected.  Both  pulse  and 
respiration  should  be  carefully  watched  during  the  anesthesia,  and  no 
time  should  be  lost  in  applying  the  proper  means  for  relief  in  case  of 
accident  of  any  sort. 

The  comparative  merits  of  ether  and  chloroform  may  be  briefly  stated 
as  follows : 

Ether  is  slower  in  its  action,  less  pleasant  to  inhale,  more  bulky  and 
more  expensive,  inflammable,  sometimes  irritating  to  the  air-passages, 

1  A.  D.  Waller,   Brit.  Med.  Join:,  April  23,  1898. 


452  INTERNATIONAL    TEXT  BOOK  OF  SURGERY. 

and  is  often  followed  by  nausea  and  vomiting;  but  it  is  safe  under  all 
ordinary  circumstances,  and  when  pure  and  properly  given,  never  results 
fatally  in  reasonably  healthy  people. 

On  the  other  hand,  chloroform,  which  is  seven  times  as  strong  as 
ether  (Waller),  is  quicker  in  its  action,  more  pleasant  to  take,  less  irri- 
tating to  the  mucous  membranes,  less  bulky  and  less  expensive,  not 
explosive,  and  is  usually  attended  by  somewhat  less  nausea  and  vomit- 
ing ;  but  it  is  not  always  safe.  Occasionally,  death  occurs  in  healthy 
persons,  early  in  the  administration  of  this  agent,  even  when  pure  and 
carefully  given,  and  the  most  searching  post-mortem  examination  fails 
to  find  any  other  satisfactory  explanation  of  the  unfortunate  occurrence. 

While  ether  is  the  safer  agent  for  ordinary  surgical  work,  yet  there 
are  certain  conditions  in  which  chloroform  is  to  be  preferred  for  special 
reasons.  Those  operations  liable  to  be  complicated  with  spasm  of  the 
glottis,  edema  of  the  larynx  or  lungs,  or  a  profuse  secretion  of  fluids  in 
the  air-passages,  can  be  done  better  and  more  safely  under  chloroform. 
This  agent,  therefore,  is  to  be  preferred  in  the  following  affections : 
Membranous  croup,  acute  or  chronic  laryngitis,  edema  of  the  glottis  or 
lungs,  injuries  to  the  larynx,  deep  cervical  cellulitis,  malignant  disease 
of  the  throat  or  anterior  portion  of  the  neck,  tumors  situated  deeply  in 
the  neck — as  bronchocele — foreign  bodies  in  the  air-passages  or  in  the 
esophagus,  chronic  bronchitis,  asthma,  and  emphysema.  Tracheotomy 
and  esophagotomy,  as  a  rule,  are  more  easily  and  safely  done  under 
chloroform,  as  there  is  less  spasm  and  less  secretion.  The  latter  agent  also 
produces  less  congestion  of  the  vessels  of  the  face  and  neck.  Chloroform 
seems  to  be  less  dangerous  in  military  than  in  civil  practice,  and,  as  it  is 
less  bulky  and  quicker  in  its  action,  it  is  preferable  to  ether  in  field-hos- 
pitals, where  time  and  transportation  are  important  factors.  By  reason 
of  its  volatility,  and  the  consequent  difficulty  of  keeping  the  drug  for  a 
long  time,  ether  will  probably  never  supplant  chloroform  in  the  tropics. 

Patients  having  advanced  disease  of  the  kidneys  are  poor  subjects 
for  either  agent,  but  many  writers  claim  that  there  is  less  irritation  of 
these  organs,  and  therefore  less  danger,  under  chloroform  than  under 
ether.  It  is  also  said  that  chloroform  causes  less  pressure  in  atherom- 
atous blood-vessels,  and  hence  is  to  be  selected  in  cases  supposed  to 
be  liable  to  apoplexy.  This  accident  is  so  very  rare  under  ether,  that 
the  opinion  would  seem  to  rest  largely  upon  theories  resulting  from 
physiological  experiments.  Advanced  cases  of  heart  disease  may  take 
ether  carefully  with  reasonable  safety.  Operations  under  any  of  these 
conditions  are  attended  with  a  certain  amount  of  danger,  aside  from  the 
influence  exerted  by  any  anesthetic.  The  smallest  possible  quantity 
should  be  given,  and  the  utmost  care  taken  in  the  administration. 

Bronchitis  and  pneumonia  seldom  result  in  this  vicinity  from  the 
administration  of  ether.  The  complication  is  too  rare  to  be  considered 
in  choosing  an  anesthetic.  Two  factors  call  for  careful  investigation 
in  connection  with  this  subject — namely,  the  quality  of  the  ether  and 
the  exposure  of  the  patient.  Certain  brands  of  this  drug  are  unfit  for 
use  by  reason  of  their  very  irritating  qualities  and  comparatively  small 
narcotic  properties.  This  matter  is  of  so  much  importance  that  many 
surgeons  in  this  part  of  the  country  will  use  only  Squibb's  ether,  than 
which,  probably,  no  better  has  ever  been  made. 


SURGICAL   ANESTHESIA,    GENERAL   AND    LOCAL.  453 

The  preservation  of  animal  heat  merits  careful  attention.  It  is  a 
fact  familiar  to  all  that  persons  are  more  susceptible  to  cold  when  asleep 
than  when  awake,  and  Dudley  P.  Allen's  experiments  upon  dogs, 
as  well  as  his  observations  upon  patients,  go  to  show  that  the  body- 
temperature  is  lowered  under  prolonged  anesthesia.  Loss  of  animal 
heat  tends  toward  collapse,  hence  the  great  importance  of  keeping 
patients  well  covered  during  anesthesia.  Exposure  of  any  considerable 
portion  of  the  body  usually  covered  and  the  application  of  wet  cloths 
are  fraught  with  danger,  and  may  be  accountable  for  a  certain  propor- 
tion of  the  cases  of  post-ether  bronchitis  and  pneumonia.  Patients 
who  are  properly  protected  and  who  inhale  a  high  grade  of  sulphuric 
ether  administered  in  a  judicious  manner  have  little  to  fear  from  any 
affection  of  the  respiratory  tract  as  a  result  of  the  anesthetic. 

Primary  anesthesia  x  has  a  limited  field  of  usefulness  in  surgery. 
Under  its  influence  simple  incisions  may  be  made,  sutures  and  drainage- 
materials  may  be  removed,  and  various  other  brief  operations  or 
manipulations  can  be  carried  out  with  satisfaction  to  the  operator  and 
without  suffering  to  the  patient.  It  is  induced  in  the  following  manner : 
Everything  being  in  complete  readiness,  that  no  time  need  be  lost  at 
the  important  moment  of  temporary  anesthesia,  the  patient  is  directed 
to  inhale  the  ether  vapor  by  drawing  in  a  few  deep  breaths.  From  a 
dozen  to  twenty  are  often  sufficient  to  produce  the  desired  effect.  The 
falling  of  the  hand,  which  the  patient  has  been  directed  to  hold  in  the 
air  unsupported,  is  a  good  index  of  the  right  moment  to  proceed  with 
the  operation.  Except  in  extremely  nervous  people,  this  method  is 
very  satisfactory  in  suitable  cases.  Little  or  no  pain  is  experienced, 
fright  is  largely  removed,  consciousness  returns  at  once,  and  there  is 
neither  nausea  nor  vomiting.  The  patient  is  in  his  usual  condition  in 
ten  or  fifteen  minutes,  and,  except  for  the  modified  pain  of  an  incision, 
for  instance,  he  goes  about  his  business  as  if  nothing  had  been  done.  In 
its  effects  and  duration  this  form  of  anesthesia  resembles  that  of  nitrous 
oxid  gas,  but  it  is  more  convenient  for  the  general  practitioner,  from  the 
fact  that  no  special  apparatus  is  necessary,  and  the  agent  is  always  at 
hand  or  is  easily  obtainable.  The  method  is  worthy  of  a  more  extensive 
use  than  it  has  ever  had  at  the  hands  of  the  profession  at  large. 

I/OCal  anesthesia1  has  considerable  value,  and  may  be  depended 
upon  for  slight  operations,  such  as  simple  incisions,  the  removal  of 
small  tumors  or  growths  in  the  skin,  etc.  More  pretentious  opera- 
tions, such  as  castration,  strangulated  hernia,  laparotomy,  and  others 
of  equal  magnitude,  have  been  done  under  its  influence;  but,  except 
in  rare  instances  and  for  special  reasons,  general  anesthesia  is  preferable 
for  this  sort  of  work,  and  is  so  considered  by  the  profession.  In  cases, 
however,  where  the  patient's  condition,  owing  to  pulmonary  disease  or 
other  causes,  does  not  admit  of  etherization,  local  anesthesia  has  a  dis- 
tinct field  in  the  performance  of  major  operations.  While  local  agents 
may  control  the  pain,  they  do  not  remove  the  dread  of  the  operation, 
hence  the  patient  cannot  always  be  depended  upon  to  keep  quiet,  which 
in  many  instances  is  an  important  factor  of  anesthesia. 

The  principal  local  anesthetics  are  cocain  hydrochlorate,  which 
stands  at  the  head  in  efficiency ;  eucain,  similar  to  the  preceding  agent, 

1  See  also  the  chapter  on  Minor  Surgery. 


454  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

but  less  poisonous;  ethyl  chlorid;  rhigolene,  not  much  used  at  present; 
carbolic  acid,  very  superficial  in  its  action  ;  ether  spray ;  and  ice,  or  ice 
and  salt.  The  field  of  usefulness  of  all  the  freezing  agents  is  rather 
limited,  from  the  fact  that  while  sensation  is  at  first  much  diminished, 
yet  the  discomfort  of  returning  sensation  is  often  as  great  as  would  be 
that  of  the  operation  itself.  They  are  useful  in  removing  wens  from 
the  scalp,  but  not,  as  a  rule,  from  other  regions  of  the  body;  in  tapping 
the  abdomen  ;  in  simple  incisions,  as  for  a  superficial  abscess,  but  not  for 
a  felon  or  palmar  abscess  or  for  any  deep  and  highly  inflamed  tissues. 

Ethyl  chlorid  l  is  one  of  the  most  convenient  of  this  class  of  agents 
for  ordinary  use,  from  the  fact  that,  as  it  is  put  up  in  small  glass  flasks, 
it  is  only  necessary  to  remove  the  cap  and  direct  the  spray  from  a 
point  about  10  inches  away  upon  the  part  desired  to  be  frozen,  which, 
in  the  space  of  a  minute  or  so,  turns  white  and  is  benumbed  sufficiently 
to  allow  of  any  of  the  above  specified  things  being  done  with  little  or  no 
pain.  The  same  result  can  be  obtained  with  ice  alone,  or  with  ice  and 
salt.  Rhigolene  and  ether  are  to  be  applied  in  the  form  of  spray,  but 
are  inferior  to  the  above-mentioned  agents,  as  their  action  is  not  so 
easily  confined  to  the  precise  area.  It  is  to  be  remembered  that  care 
and  judgment  are  always  to  be  exercised  in  applying  cold  as  well  as 
heat  to  the  bod}',  as  ulceration  and  even  sloughing  may  be  produced 
almost  as  readily  with  one  class  of  agents  as  with  the  other. 

Cocain,  the  alkaloid  from  the  leaves  of  coca — a  shrub  which  grows 
in  Peru  and  Bolivia — was  discovered  by  Gaedeke  in  1855,  but  it 
has  been  in  general  use  as  a  local  anesthetic  only  about  ten  years. 
Dissolved  in  water  in  the  proportion  of  1  :  1000  or  500 — i.  e.,  a  strength 
of  from  y1^-  to  ^  per  cent. — the  hydrochlorate  of  cocain  is  probably  the 
best  local  anesthetic  known  to  the  profession  to-day.  There  are  two 
precautions  to  be  borne  in  mind  in  using  this  agent.  The  first  is  the 
marked  depressing  action  upon  the  heart  and  brain,  and  the  other  is 
the  pernicious  appetite  which  may  be  established  for  the  drug.  The 
cocain  habit  seems  to  be  more  powerful  than  that  for  morphin,  and  it  is 
more  difficult  to  break  up  and  eradicate.  Given  in  the  proportions  and 
for  the  purposes  mentioned  in  this  article,  there  is  very  little  danger  to 
be  apprehended  from  the  use  of  this  valuable  drug.  The  agent  is 
probably  as  efficacious  when  it  is  dissolved  in  water  and  used  alone 
as  when  given  with  morphin,  atropin,  or  other  narcotics.  Applied  to 
mucous  membranes,  it  is  readily  absorbed,  exerts  its  specific  effect  in  a 
short  time,  and  produces  an  anesthesia  lasting  about  a  quarter  of  an 
hour.  The  effects  of  this  drug  vary  not  only  in  individuals,  but  also 
in  different  regions  of  the  same  person,  some  being  much  more  sus- 
ceptible to  its  influence  than  others.  The  mucous  membrane  of  the 
eye  appears  to  be  especially  sensitive  to  its  action,  and  therefore  the 
agent  is  of  especial  value  in  operations  and  manipulations  of  this  organ. 
The  same  may  be  said  of  the  nose  and  throat.  The  action  of  cocain 
upon  the  lining  of  the  urethra  is  neither  quite  as  safe  nor  as  satisfactory 
as  upon  the  organs  above  mentioned.  Fatal  results  have  followed  its 
application  to  this  region  (Hare,  Park's  Surgery)  ;  hence  very  weak 
solutions  should  be  used  in  the  urethra  and  nose,  not  over  2  per 
cent.,  and  they  may  well  be  even  weaker  than  this  at  first.     For  the 

1  See  also  the  chapter  on  Minor  Surgery. 


SURGICAL   ANESTHESIA,    GENERAL   AND   LOCAL.  455 

eye  a  2  per  cent,  solution  is  often  strong  enough,  but  for  the  vagina 
and  rectum  a    10  per  cent,  strength  may  be  required. 

Infiltration  Anesthesia.1 — For  operations  involving  the  skin  and 
subjacent  tissues,  the  method  of  producing  local  anesthesia  by  infiltra- 
tion, as  proposed  by  Schleich  of  Berlin' in  1891,  is  probably  the  best 
yet  suggested.  By  this  method,  it  is  said,  all  tissues  except  inflamed 
bone  can  be  rendered  anesthetic.  The  technic  is  simple,  the  solution  is 
weak,  and  the  results  are  usually  satisfactory.  The  site  of  the  injection 
is  to  be  washed  with  soap  and  water,  and  then  with  bichlorid  solution, 
1  :  5000 ;  the  syringe  is  to  be  boiled  ;  in  short,  aseptic  precautions  are  to 
be  carried  out  as  in  ordinary  minor  surgical  operations.  The  solutions 
suggested  by  Schleich  are  of  three  strengths.  The  medium  and  most 
useful  one  contains  1  grain  cocain  hydrochlorate,  \  grain  morphin  hydro- 
chlorate,  and  2  grains  common  salt  to  1000  minims  of  water.  The  stronger 
solution,  for  use  in  inflamed  tissues,  contains  double  the  amount  of  cocain ; 
and  the  weaker,  TV  grain  of  the  drug.  The  tablets  of  Wyeth  and 
Brother,  made  in  accordance  with  the  above  schedule,  are  the  most 
convenient  form  for  common  use.  To  produce  anesthesia  of  the  skin,  it 
is  necessary  to  inject  the  cocain  into,  and  not  under  it,  as  the  peculiar 
influence  of  the  drug  does  not  permeate  the  skin  from  the  cellular  tis- 
sue. The  anesthetic  area  is  white,  more  or  less  edematous  in  the  form 
of  wheals,  and  about  \  inch  in  diameter.  The  effects  of  the  agent  last 
from  fifteen  to  twenty  minutes,  and  are  more  pronounced  when  it  can 
be  confined  to  the  part  by  an  elastic  band,  as  in  a  finger,  toe,  or  the 
penis.  To  render  inflamed  tissues  anesthetic,  it  is  necessary  to  surround 
them  by  a  zone  of  narcotized  healthy  skin,  and  from  that  to  extend 
the  injections  into  the  desired  area.  It  is  doubtful  if  this  process  has 
any  advantages  over  primary  or  general  anesthesia  in  operating  upon 
inflamed  structures.  The  mental  peculiarities  of  the  individual  must  be 
taken  into  account.  Very  many  people  would  not  care  to  undergo  the 
mental  strain  of  realizing  that  an  operation  was  being  performed  upon 
them.  Judgment,  tact,  and  skill  are  requisite  in  the  use  of  those  agents, 
in  order  that  the  greatest  benefit  may  be  derived  from  their  application. 

Eucain,  as  a  substitute  for  cocain,  has  been  employed  to  some 
extent  as  a  local  anesthetic  in  the  strength  of  1  to  2  per  cent.,  and  to 
the  amount  of  1^  grains  and  upward.  "Eucain  B"  is  said  to  be  less 
irritating  than  "  Eucain  A,"  but  the  limit  of  safety  has  not  been  accu- 
rately determined.  The  advantages  claimed  over  cocain  are  the  lessened 
danger  of  cardiac  depression,  the  longer  duration  of  the  narcosis,  and 
that  neither  time  nor  heat  impairs  its  strength,  thus  allowing  the  solu- 
tion to  be  boiled  before  using.     Heat  impairs  the  cocain  solutions. 

The  anesthetic  influence  of  eucain  is  slower  in  its  manifestation 
than  it  is  from  the  other  agent.  The  most  damaging  report  about  it 
is  of  the  frequent  occurrence  of  local  sloughing  in  operations  "  in  fatty 
tissue,  upon  the  fingers  and  toes,  the  prepuce,  and  bursal  and  tendon 
sheaths."  In  consideration  of  the  very  minute  quantity  of  cocain 
required  in  cases  suitable  for  local  anesthesia,  it  hardly  seems  to  the 
writer  that  the  claims  for  the  superiority  of.  eucain  over  the  former 
agent  have  been  proved.     Further  light  on  this  subject  is  desirable. 

Holocain. — Hasket  Derby,  of  Boston,  has  used  holocain  (1  per  cent, 
solution)  for  some  years,  and  has  come  to  the  following  conclusions : 

1  See  also  the  chapter  on  Minor  Surgery. 


456  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

"As  compared  with  cocain,  it  possesses  many  advantages  as  regards 
its  use  in  ophthalmic  surgery.  It  does  not  enlarge  the  pupil,  which  is 
a  very  great  gain,  both  on  the  ground  of  present  inconvenience  and  as 
tending  to  increase  pressure.  Moreover,  it  does  not  cloud  the  cornea 
or  disturb  its  epithelial  layer,  as  is  sometimes  the  case  with  cocain.  It 
never  brings  about  the  pallor  or  collapse  that  characterizes  the  action 
of  cocain  with  a  few  sensitives.  It  is  a  perfect  anesthetic.  Its  solution 
remains  permanently  sterile,  and  its  bactericidal  properties  give  its 
application  much  value  in  certain  forms  of  corneal  ulcer.  In  short,  it 
will  do  everything  that  cocain  will,  except  modify  the  hemorrhage  that 
attends  the  operation. 

"  On  the  other  hand,  its  application  is  attended  at  first  by  slight 
pain  ;  and  it  cannot  be  injected  subcutaneously,  neither  can  it  be  used 
in  sufficient  quantity  to  allay  the  pain  attending  the  introduction  of  a 
lacrimal  probe.     Here  cocain  has  its  place." 

1NTRA=SPINAL  COCAINIZATION. 

The  injection  of  solutions  of  cocain  into  the  spinal  canal  to  produce 
anesthesia  has  been  extensively  investigated  and  practised  by  Tuffier 
at  the  Hospital  Beaujon,  Paris,  his  first  report  on  the  subject  appearing 
in  1899.  This  method  has  been  tried  by  various  men  in  America,  but 
the  opinions  of  the  majority  have  discouraged  its  use. 

A  sufficiently  large  area  on  the  patient's  back  in  the  lumbar  region 
is  made  thoroughly  aseptic  as  for  operation.  The  operator's  hands  are 
also  carefully  made  aseptic.  The  patient  should  be  sitting  with  his 
back  toward  the  operator,  and  slightly  bent  forward  so  as  to  separate 
the  laminae  of  the  vertebrae.  The  two  highest  points  of  the  iliac  crests 
are  defined.  A  horizontal  line  connecting  these  should  pass  between 
the  fourth  and  fifth  lumbar  vertebrae.  Palpating  with  the  thumb,  the 
lower  border  of  the  fourth  lumbar  spinous  process  is  defined,  and  its 
position  marked  on  the  skin  with  the  thumb-nail.  A  sterilized  platinum 
needle,  2\  or  3  inches  long  and  with  a  short-beveled  point,  is 
used.  This  is  entered  in  an  upward  and  inward  direction  about  1  cm. 
to  one  side  of  the  mark  made  on  the  skin  to  indicate  the  lower  edge  of 
the  fourth  lumbar  spinous  process.  When  the  spinal  canal  is  entered, 
a  few  drops  of  clear  serous  fluid,  slightly  tinged  with  blood  from  the 
needle-wound,  will  appear  at  the  external  orifice  of  the  needle.  Three 
or  four  drops  of  this  are  allowed  to  flow,  and  then  a  sterilized  glass 
syringe  of  2  c.c.  capacity,  and  containing  a  freshly  made  and  sterilized 
2  per  cent,  solution  of  cocain  hydrochlorate,  is  fitted  to  the  needle. 
Two  centigrams  of  the  solution  are  slowly  injected.  The.  needle  is 
then  withdrawn,  and  the  puncture  aseptically  sealed  with  collodion. 

Anesthesia  usually  occurs  in  from  five  to  fifteen  minutes,  and  often 
extends  from  the  nipples  or  axillae  above  to  the  ankles  below. 

This  method  often  fails  to  produce  anesthesia,  and  is  so  often 
attended  by  symptoms  of  cocain  poisoning — nausea  and  vomiting, 
profuse  sweating,  pallor,  headache,  rapid  pulse,  failing  respiration — 
that  it  will  probably  never  have  a  place  in  surgery.  Deaths  continue 
to  be  reported  from  spinal  cocainization,  and  all  the  resources  of  inhala- 
tion anesthesia  should  be  exhausted  before  resorting-  to  this  method. 


NITROUS   OXID,    ETC. 


457 


NITROUS    OXID;    NITROUS    OXID    AND    OXYGEN;    NITROUS    OXID 
AND  ETHER;  CHLOROFORM-MKTURES. 

The  anesthetics  commonly  employed  in  England  at  the  present  time 
are  nitrous  oxid  gas  (either  alone  or  mixed  with  oxygen),  ether,  chlo- 
roform, and  mixtures  of  ether  and  chloroform  in  various  proportions. 

Nitrous  oxid  is  largely  used  for  dental  and  other  short  operations 
requiring  only  brief  anesthesia.  Its  chief  advantages  are  I.  Its  great 
safety ;  2.  Absence  of  the  necessity  for  elaborate  preparation  of  the 
patient;  3.  Speedy  induction  of  anesthesia  ;  4.  Quick  recovery  without 
unpleasant  after-effects. 

It  can  safely  be,  and  generally  is,  administered  to  patients  sitting 
upright  in  a  chair,  the  head  being  perfectly  supported  and  as  nearly  as 
possible  in  a  line  with  the  body. 
No  food  should  be  taken  imme- 
diately beforehand,  though  it  is 
not  necessary  to  insist  on  a  fast 
of  several  hours,  as  in  the  case 
of  ether  and  chloroform.  Care 
must  be  taken  that  the  clothing 
is  quite  loose  around  the  neck, 
chest,  and  abdomen,  so  that  no 
obstruction  to  respiration  shall  be 
present.  Any  movable  artificial 
teeth  should  be  removed  from  the 
mouth,  and  for  dental  operations 
a  small  prop  must  be  inserted  on 
the  side  of  the  mouth  opposite 
that  on  which  the  operation  is  to 
be  performed. 

Several  forms  of  apparatus  are 
used  in  England  for  the  adminis- 
tration of  nitrous  oxid  ;  that  of 
Frederic  Hewitt  is  very  com- 
monly employed,  and  is  satisfac- 
tory and  convenient. 

B  is  an  india-rubber  bag  of  two  gallons' 
capacity,  into  which  the  gas  passes  from  the 
cylinders  C,  C.  At  the  upper  end  of  the  bag 
is  the  stopcock  SC,  containing  an  inspiratory 
andan  expiratory  valve.  When  the  small  han- 
dle h  is  in  the  position  shown  in  the  figure, 
the  contents  of  the  bag  are  shut  off  from  the 
stopcock  and  face-piece,  so  that  the  patient 
breathes  only  air,  inspiring  and  expiring 
through  the  valves.  When  the  handle  h  is 
pushed  up,  the  bag  is  put  into  connection 
with  the  stopcock  and  the  patient  inhales 
gas  from  the  bag!  and  expires  into  the  air, 
still  breathing  through  the  valves.  The 
handle  d,  at  the  end  of  the  stopcock,  works 
an    inner   casing  which    carries  the  valves, 

and  the  arrangement  is  such  that  when  d  is  turned  round,  the  valves  are  put  out  of  action, 
and  the  patient  simplv  breathes  into  and  out  of  the  bag.  The  bag  is  first  nearly  filled  from 
the  cylinder  by  turning  the  foot-key,  and  the  face-piece  applied  to  the  patient's  face.  He 
is  then  told  to  breathe  deeply  and  regularly,  and  gas  is  admitted  by  means  of  the  handle  //. 


Fig.  185. — Hewitt's  nitrous  oxid  apparatus. 


458  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

The  foot  of  the  administrator  is  kept  on  the  foot-key,  and  a  steady  stream  of  gas  is  allowed 
to  run  into  the  bag.  The  valves  are  usually  allowed  to  act  throughout  the  administration  ; 
but  in  some  cases,  where  a  rather  longer  anesthesia  is  required,  the  handle  d  is  turned 
round  toward  the  end  of  the  administration,  and  the  patient  is  thus  caused  to  rebreathe 
the  gas  which  he  has  expired.  As  the  inhalation  proceeds,  the  respirations  become  deeper, 
and  finally  stertorous,  the  face  gets  dusky,  and  muscular  twitchings  of  the  limbs  and  body 
occur.  When  anesthesia  is  complete,  the  pupils  are  more  or  less  dilated  and  the  con- 
junctiva insensitive  to  the  touch.  The  face-piece  is  now  removed  and  the  operation  is 
performed.      The  time  taken  to  produce  anesthesia   is  generally  from  thirty  to  sixty  seconds. 

The  chief  objection  to  the  use  of  nitrous  oxid  alone  is  the  occur- 
rence of  symptoms  of  asphyxia,  due  to  the  deprivation  of  air.  These 
symptoms  are — i.  Cyanosis;  2.  Stertor  ;  3.  Jerking  of  the  muscles. 

They  are  especially  apt  to  occur  in  children  and  anemic  persons, 
who  also  "  come  round  "  very  quickly,  giving  a  very  short  period  of 
efficient  anesthesia.  The  muscular  twitchings,  too,  are  sometimes  so 
excessive  as  seriously  to  interfere  with  the  operation.  In  the  case  of 
very  anemic  women,  there  is,  besides,  a  certain  danger  of  respiratory 
or  cardiac  failure  during  the  administration  of  nitrous  oxid  alone ;  and 
in  old  people  with  atheromatous  arteries  there  may  be  some  risk,  owing 
to  the  strain  thrown  on  the  circulation.  The  asphyxial  symptoms  may 
be  diminished  or  abolished  by  giving  a  few  breaths  of  air  during  the 
administration.  But  a  more  accurate  method  is  that  of  Hewitt,  in  which 
a  small  quantity  of  oxygen  is  gradually  mixed  with  the  nitrous  oxid  by 
means  of  a  specially  devised  apparatus.  With  this  it  is  possible  to 
increase  or  diminish  the  oxygen  by  very  small  amounts,  so  that  the 
amounts  inhaled  are  accurately  under  the  control  of  the  administrator. 
The  advantages  of  this  method,  which  is  now  extensively  employed  in 
England,  are — 

1.  The  elimination  of  the  asphyxial  symptoms  mentioned  above, 
with  the  production  of  tranquil  anesthesia. 

2.  A  longer  period  of  anesthesia  available  after  the  face-piece  has 
been  removed. 

Hewitt  gives  about  forty-four  seconds  as  the  average  period,  as 
against  thirty-five  seconds  with  nitrous  oxid  alone. 

B  is  a  large  india-rubber  bag,  divided  into  two  equal  compartments  which  do  not  com- 
municate, one  for  nitrous  oxid,  the  other  for  oxygen.  The  respective  gases  pass  from  the 
cylinders  C,C,C  into  the  compartments  of  the  bag  on  turning  the  foot-keys  A',  A'.  The  tube 
conveying  the  oxygen  passes  inside  that  conveying  the  nitrous  oxid  for  nearly  the  whole  dis- 
tance, but  the  two  separate  on  reaching  the  bag.  To  the  upper  end  of  the  double  bag  is 
fitted  the  most  important  part  of  the  apparatus — viz.,  the  stopcock  through  which  the  gases 
pass  on  their  way  to  the  face-piece.  The  tubes  /,  /  of  this  stopcock  are  each  provided  with  a 
valve  acting  during  inspiration,  so  that  the  gases  do  not  mix  before  reaching  the  mixing 
chamber  MC.  This  chamber  occupies  the  greater  part  of  the  stopcock,  and  to  it  the  gases 
are  admitted  by  moving  the  handle  //.  When  the  pointer  of  this  handle  points  to  the  word 
"Air"  on  the  dial-plate  d,  air  only  can  be  breathed  ;  when  it  is  moved  round  so  as  to  point 
to  "  N,0,"  nitrous  oxid  is  admitted,  and,  as  it  travels  further,  oxygen  enters  in  addition. 
The  nitrous  oxid  enters  the  mixing  chamber  directly  from  the  tube  t.  The  oxygen  first 
enters  the  oxygen-chamber  oc,  and  thence  passes  to  the  mixing  chamber  through  a  series  of 
ten  small  holes,  which  are  opened  one  by  one  as  the  handle  //  is  moved  round,  and  are  indi- 
cated by  the  figures  I  to  io  on  the  dial-plate.  Between  the  mixing  chamber  and  the  face-piece 
Fare,  two  valves,  one  acting  during  inspiration,  the  other  during  expiration,  so  that  if  the 
face-piece  fits  properly,  the  patient  must  inhale  from  the  apparatus  and  expire  into  the  air. 
The  two  compartments  of  the  bag  are  first  nearly,  but  not  quite,  filled  with  the  respective 
gases,  the  pointer  of  the  handle  pointing  to  "Air."  There  should  not  be  a  positive  pressure 
in  the  bag.  The  face-piece  is  then  accurately  applied,  and  the  patient  told  to  breathe 
deeply  and  regularly.  The  handle  is  now  turned  so  as  to  admit  nitrous  oxid,  and  then 
immediately  to  I  or  2  on  the  dial-plate.  The  patient  is  now  breathing  nitrous  oxid  with  a 
very  small  per  cent,  of  oxygen.      The  proportion  of  oxygen  admitted  to  the  mixing  chamber 


NITROUS    OX  ID,    ETC. 


459 


is  so  small  that  the  quantity  first  let  into  the  bag  is  quite  sufficient  for  an  administration,  and 
no  further  supply  from  the  cylinder  will  be  needed,  but  a  constant  stream  of  nitrous  oxid 
must  be  admitted  to  the  bag,  by  means  of  the  foot-key,  to  supply  the  place  of  that  inspired 
and  expired  by  the  patient.  In  this  way  the  compartments  of  the  bag  can  be  kept  equal  in 
size  throughout  the  administration,  a  point  which  must  be  carefully  attended  to. 


Fig.  186. — Hewitt's  nitrous  oxid  and  oxygen  apparatus. 


The  amount  of  oxygen  given  must  depend  on  the  sort  of  patient 
with  whom  we  have  to  deal.  In  children,  anemic  women,  and  aged 
persons,  it  may  be  admitted  rapidly,  beginning  with  the  pointer  at  I, 
and  proceeding  one  number  at  a  time  every  two  or  three  breaths,  until 
the  maximum  (10)  is  reached.  If  any  sign  of  cyanosis,  stertor,  or 
twitching  of  the  muscles  appear,  the  oxygen  should  be  increased  more 
rapidly ;  if,  on  the  other  hand,  there  are  symptoms  of  excitement,  cry- 
ing out,  etc.,  it  should  be  given  more  slowly  or  diminished.  In  dealing 
with  robust,  full-blooded  patients,  caution  must  be  observed  in  increas- 
ing the  oxygen,  as  symptoms  of  excitement  are  apt  to  occur. 

The  average  time  required  for  the  induction  of  anesthesia  is,  accord- 
ing to   Hewitt,  one  hundred   and  ten   seconds.     At  the  end  of  that 


460 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


time,  if  the  case  has  progressed  favorably,  the  patient  should  be  tran- 
quil, breathing  quietly  with  perhaps  slight  stertor,  the  color  natural,  the 
pupils  contracted,  the  conjunctiva  insensitive,  and  the  muscles  relaxed. 
If  the  operation  be  one  about  the  mouth,  the  face-piece  is  now  removed 
and  the  operator  proceeds.  If  the  site  of  operation  be  away  from  the 
mouth,  the  face-piece  can  be  kept  in  position  and  the  anesthesia  main- 
tained for  ten  or  fifteen  minutes  very  satisfactorily.  In  these  cases  it 
may  be  found  that  the  patient  becomes  cyanosed  even  with  the  maxi- 
mum amount  of  oxygen,  and  that  it  is  necessary  to  give  an  occasional 
breath  of  air  by  raising  the  face-piece.  It  has  been  employed  for  longer 
operations  of  half  an  hour  and  more,  but  in  such  prolonged  administra- 
tions it  is  difficult  to  maintain  a  uniform  degree  of  anesthesia  and  to 
keep  the  patient  quiet  and  relaxed  throughout ;  also  a  good  deal  of 
sickness  and  discomfort  is  likely  to  occur  after  these  cases.  On  the 
other  hand,  after  short  administrations,  the  patient  generally  recovers 
almost  as  quickly  as  after  nitrous  oxid  alone,  and  without  disagreeable 
after-effects.  It  follows,  therefore,  that  for  long  operations  ether  or 
chloroform  is  to  be  preferred. 

Administration  of  Nitrous  Oxid  and  Ether — The  induction  of 
anesthesia  with  nitrous  oxid  and  its  maintenance  with  ether  has  lone 
been  practised  in  England,  and  is  now  done  considerably  in  America. 
It  is  more  agreeable  for  the  patient  than  ether  alone,  saving  him  all 
odor  and  sense  of  suffocation,  and  plunging  him  rapidly  and  safely  into 
deep  anesthesia  without  struggling  or  excitement. 

The  most  satisfactory  are  those  forms  of  apparatus  which  furnish 


Fig.  187. — Clover's  portable  regulating  ether-inhaler. 


both  gas  and  ether,  and  by  their  mechanism  place  the  transition  from 
one  agent  to  the  other  under  easy  control  of  the  anesthetist.  Such 
are  the  Clover-Hewitt  (London)  and  the  Bennett  (New  York)  com- 
bined gas-  and  ether-inhalers. 

The  Clover-Hewitt  apparatus  is   much  used  in  England,  but  little, 
if  at  all,  in  the  United  States.     It  consists  of  a  Clover's  ether-inhaler 


NITROUS    OX  ID,    ETC. 


461 


(Fig.  187)  used  in  combination  with  the  bag  of  Hewitt's  nitrous  oxid 
apparatus  (Fig.  185). 

Administration. — The  ether-chamber  is  charged  with  ether  and 
fitted  with  a  suitable  face-piece.  The  bag  is  filled  with  gas  from 
the  cylinder,  the  handle  //  (Fig.  185)  shutting  off  the  gas  from  the 
stopcock. 

The  distended  bag  can  then  be  detached  from  the  supply-tube,  the 
gas  being  prevented  from  escaping  at  the  lower  end  by  turning  the  tap 
Jy  The  amount  of  gas  in  the  bag  is  quite  sufficient  for  one  adminis- 
tration. The  inhaler  is  applied  to  the  face,  and  the  distended  gas-bag 
fitted  to  it.  Air  is  first  freely  breathed  through  the  valves.  The  gas 
is  next  put  into  communication  with  the  inhaler,  so  that  the  patient 
now  inspires  gas  and  expires  into  the  air,  the  valves  being  in  action. 
The  pointer  of  the  indicator  all  this  time  stands  at  O.  A  very  few 
deep  breaths  are  enough  to  cause  unconsciousness,  and  when  about 
half  the  gas  in  the  bag  has  been  exhausted,  the  valves  are  put  out  of 
action  by  the    handle  h,  and    the    patient    breathes   into   and   out  of 


Fig.  188. — Bennett's  gas-  and  ether-inhaler. 


the  bag.  The  ether  is  now  gradually  turned  on,  though  the  rotation 
of  the  ether-chamber  is  more  rapid  than  when  gas  is  not  used.  Thus, 
ether-vapor  is  mixed  with  the  gas,  and  the  patient  is  very  soon  under 
its  influence.  No  air  should  be  given  until  the  anesthesia  is  com- 
plete, which  should  be  in  from  two  to  three  minutes  from  the  com- 
mencement. The  breathing  will  now  be  stertorous,  and  there  will  be 
some  amount  of  cyanosis.  The  large  bag  is  removed  at  this  stage 
and  the  small  ether-bag  put  in  its  place,  air  being  then  admitted  for  the 
first  time. 

An  improvement  on  the  Clover-Hewitt,  and  probably  the  most 
satisfactory  apparatus  for  administering  gas  and  ether,  is  the  one 
invented  by  Thomas  L.  Bennett,  of  New  York,  and  now  used  in  the 
principal  New  York  Hospitals. 

Bennett's  apparatus  consists  of  (1)  a  metal  face-piece  with  an  inflat- 
able rubber  cushion  and  an  air-tap,^  (Fig.  188);  (2)  a  metal  ether- 
chamber  B,  which  connects  with  the  face-piece.     The  ether-chamber 


462  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

contains  a  wire  cage,  which  is  firmly  packed  with  gauze  for  each 
administration.  The  cage  is  smaller  than  the  chamber,  and  thus  leaves 
a  considerable  space  for  the  passage  of  air  around  the  gauze.  Tunnel- 
ling the  ether-chamber  and  cage  is  an  air-shaft.  The  mechanism  is 
such  that,  having  saturated  the  gauze  in  the  chamber  with  ether,  and 
turned  the  thumb-screw  so  that  the  indicator  points  to  "air,"  ether  is 
shut  off  and  the  air-shaft  is  made  to  communicate  with  the  face-piece, 
and  at  its  upper  end  with  the  gas-chamber.  This  is  provided  with 
an  inspiratory  and  an  expiratory  valve,  which  may  be  thrown  out  of 
action  by  turning  the  thumb-screw.  It  connects  at  its  lower  end  with 
the  ether-chamber,  and  at  its  upper  end  with  the  gas-bag.  This 
has  a  capacity  of  about  two  gallons,  which  is  enough  for  one  adminis- 
tration. It  is  fitted  with  an  air-tap  E  and  a  stopcock  F.  The  ether- 
bag  fits  onto  the  ether-chamber  after  removal  of  the  gas-chamber. 

Administration} — The  ether-chamber  is  charged  with  ether,  and  the 
stopcock  turned  so  that  the  indicator  is  at  "  air."  The  gas-bag  is 
filled  with  gas,  detached  from  the  tube  at  the  stopcock  F,  and  fitted  to 
the  gas-chamber.  The  gas-chamber  is  now  connected  with  the  ether- 
chamber.  The  face-piece  being  properly  applied,  air  enters  at  E  and  is 
breathed  through  valves.  The  tap  E  is  now  closed,  and  gas  is  breathed 
through  valves.  When  the  bag  has  been  two-thirds  emptied,  the  aper- 
ture D  is  closed  by  turning  the  thumb-screw  of  the  gas-chamber. 
Gas  is  now  breathed  back  and  forth.  The  patient  is  at  this  time 
unconscious  or  nearly  so,  and  the  index  is  turned  toward  "ether"  as 
slowly  as  is  necessary  to  avoid  the  effects  of  too  strong  ether  fumes, 
until  the  upward  limit  of  the  index,  or  "  full  ether,"  is  reached. 

In  about  one  minute  signs  of  complete  anesthesia  will  appear  if  the 
face-piece  has  been  well  applied  (cyanosis,  jerky,  snoring  respiration, 
twitching  movements  in  the  extremities),  and  are  to  be  met  by  opening 
the  tap  E  for  two  or  three  respirations.  The  tap  is  again  closed,  and 
the  inhalation  of  gas  plus  ether  is  continued,  an  occasional  breath  or 
two  of  air  being  allowed.  In  this  way  the  gas  anesthesia  subsides 
while  the  ether  narcosis  becomes  complete.  After  about  one  and  a 
half  minutes  the  gas  may  be  discontinued ;  the  gas  inhaler  and  bag 
should  be  removed,  and  the  ether-bag  substituted. 

When  anesthesia  is  complete,  it  may  be  maintained,  if  desired,  by 
an  open  cone,  although  in  skilled  hands  very  satisfactory  results  are 
obtained  by  continuing  with  the  Clover  or  Bennett  ether-inhaler. 

Braincs1  Method. — A  full  dose  of  nitrous  oxid  is  given  from  any  of 
the  numerous  gas-inhalers  used  in  dentistry,  and  the  anesthesia  thus 
induced  is  maintained  by  changing  to  an  ordinary  ether-cone  or  other 
form  of  ether-inhaler. 

To  perform  successfully  this  method  requires  long  practice,  and  in 
unskilled  hands  it  is  usually  attended  by  a  large  percentage  of  failures. 
When  signs  of  complete  gas  anesthesia  appear,  the  face-piece  should 
be  removed  during  an  expiration. 

According  to  the  degree  of  cyanosis,  the  following  inspiration 
should  be  of  air  or  of  ether.  To  control  the  patient  it  is  usually 
necessary  to  prevent  at  first  a  rather  strong  ether-vapor,  and  this  is  apt 
to  result  in  a  disconcerting  or  even  dangerous  degree  of  reflex  apnea. 

1  The  following  directions  are  from  the  circular  which  is  sold  with  the  Bennett  apparatus. 


NITROUS   OX  ID,    ETC.  463 

Much  more  gas  is  required  than  in  the  combined  inhalers,  and  the 
apparatus  is  usually  cumbersome. 

The  nitrous-oxid-ether  sequence  is  safe  and  satisfactory  in  most 
cases.  It  should  be  used  with  great  caution,  if  at  all,  in  very  young 
children  and  in  the  aged.  It  should  not  be  used  when  respiratory 
affections  or  atheroma  is  present.  It  should  be  used  with  great 
caution,  if  at  all,  in  cardiac  cases. 

Administration  of  Chloroform. — Chloroform  should  always  be 
given  by  the  open  method — i.  c,  with  a  free  admixture  of  air. 

One  of  the  simplest  and  best  inhalers  is  a  piece  of  lint  folded  on 
itself  so  as  to  make  a  square  piece  of  double  thickness,  measuring 
five  or  six  inches.     There  are  several  advantages  in  this  : 

1.  The  evaporation  of  the  vapor  is  very  rapid,  and  the  admixture  of 
air  very  free. 

2.  There  is  little  danger  of  blistering  the  face,  as  the  lint  does  not 
get  soaked  with  the  liquid,  and  is  held  slightly  off  the  face. 

3.  It  frightens  children  much  less  than  a  more  bulky  apparatus. 

A  few  drops  of  chloroform  are  sprinkled  on  the  lint  from  a  drop 
bottle,  and  the  lint  is  at  first  held  at  some  little  distance  from  the  face. 
Very  soon  more  is  added,  and  this  is  done  at  short  intervals,  before  the 
previous  supply  has  entirely  evaporated,  each  time  slightly  increasing  the 
dose,  and  turning  the  lint  with  the  wet  side  toward  the  face.  The  lint 
is  also  brought  closer  to  the  face,  but  without  allowing  it  to  touch. 
The  strength  of  the  vapor  is  thus  gradually  increased,  so  that  the 
patient  soon  becomes  accustomed  to  it  without  any  disagreeable  sense 
of  suffocation,  and  breathes  freely.  The  struggling  stage  is  soon 
reached,  and  here  great  care  must  be  observed,  especially  if  the  strug- 
gling is  violent.  If  the  respiration  is  free,  the  administration  should  be 
steadily  continued  by  small,  frequent,  and  gradually  increasing  doses. 
If  any  respiratory  obstruction  occurs,  the  administration  must  be  with- 
held till  the  breathing  is  free  again.  This  may  usually  be  effected  by 
drawing  forward  the  lower  jaw.  The  pupils  at  this  stage  are  usually 
dilated.  The  patient  soon  passes  into  a  state  of  tranquil  anesthesia,  the 
muscles  are  relaxed,  the  breathing  regular,  the  pupils  contracted,  and 
the  conjunctiva  insensitive.     The  operation  may  now  be  begun. 

From  this  point  the  anesthesia  is  to  be  maintained  as  far  as  possible 
at  the  same  level.  The  chloroform  is  no  longer  increased  each  time, 
but  small  doses  are  frequently  administered.  At  no  time  should  a 
large  quantity  be  added,  and  as  the  operation  proceeds  the  amount 
should  be  decreased  gradually,  for  the  longer  the  anesthesia  lasts  the 
less  chloroform  is  required. 

A  careful  watch  should  be  kept  on  the  pupils,  which  should  be 
maintained  at  their  greatest  possible  degree  of  contraction.  This  is 
best  done  by  a  steady  and  frequent  addition  of  small  quantities  of 
chloroform.  If  dilatation  occurs,  it  may  be  either  a  reflex  effect  due  to 
insufficient  anesthesia  or  the  result  of  an  overdose.  In  the  first  case 
conjunctival  reflex  will  usually  be  present,  in  the  latter,  absent;  but  if 
there  is  any  doubt  as  to  the  cause  of  the  dilatation,  the  anesthetic  must 
be  withheld  till  the  doubt  is  removed. 

The  respiration  is  to  be  watched  very  carefully.  If  any  obstruction 
occurs,  the  chin  must  be  drawn  forward,  or  the  mouth  opened  and  the 


464  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

tongue  drawn  out  of  the  mouth.  If  the  respirations  become  shallow 
and  the  face  pale,  the  anesthetic  must  be  stopped,  the  head  lowered,  the 
tongue  drawn  forward,  and,  if  necessary,  artificial  respiration  performed. 

The  condition  of  the  pulse  must  be  carefully  attended  to  through- 
out the  administration.  Under  chloroform  there  is  a  liability  to  de- 
pression of  the  circulation,  and  any  failure  of  the  pulse  should  be  a 
warning  to  diminish  or  discontinue  the  anesthetic. 

During  a  lengthy  operation,  if  the  pulse  begins  to  fail  and  the 
patient  shows  other  signs  of  faintness,  it  is  a  good  plan  either  to  change 
to  ether,  or  to  mix  equal  parts  of  ether  and  chloroform  in  the  drop- 
bottle  and  administer  the  mixture  on  lint.  The  pulse  will  generally 
improve  under  the  stimulation  of  the  ether,  and  the  patient  be  enabled 
to  go  through  the  rest  of  the  operation  without  further  trouble. 

In  slight  degrees  of  faintness,  sharp  rubbing  of  the  lips  and  face 
with  a  warm  dry  towel  acts  as  an  excellent  stimulant,  causing  both 
pulse  and  color  to  improve.  In  cases  of  serious  respiratory  or  cardiac 
failure,  artificial  respiration  should  be  at  once  resorted  to,  first  seeing 
that  the  way  is  clear  for  the  entrance  of  air  to  the  lungs.  Sylvester's 
method  is  the  most  satisfactory,  and  should  be  performed  deliberately, 
the  chest  being  compressed  not  more  than  sixteen  times  in  the  minute, 
and  sufficient  time  allowed  for  its  thorough  expansion  after  each  com- 
pression. Ether  may  be  injected  subcutaneously,  and  heat  and  elec- 
tricity applied  ;  but  they  should  not  interfere  with  the  artificial  respira- 
tion, which  is  by  far  the  most  important  means  of  resuscitation. 

Chloroform,  as  has  been  said  before,  is  borne  better,  and  the  danger 
of  cardiac  and  respiratory  failure  is  much  less,  if  anesthesia  has  been 
induced  by  ether  or  nitrous  oxid  and  ether.  This  should  always  be 
done  if  possible,  the  patient  being  placed  fully  under  the  influence  of 
ether,  and  thus  efficiently  stimulated.  Children  take  chloroform  well, 
but  are  easily  overdosed,  so  great  care  should  be  taken  to  add  the 
anesthetic  in  very  small  quantities  and  to  give  air  freely. 

A.  C.  E.  and  other  Mixtures. — The  A.  C.  E.  mixture  is  administered 
generally  by  means  of  a  leather  or  celluloid  inhaler  containing  a 
sponge,  and  having  holes  in  the  top  for  the  admission  of  air.  Other 
mixtures  containing  a  larger  proportion  of  chloroform  may  be  given 
on  lint. 

A.  C.  E.  is  often  used  as  a  preliminary  to  ether  in* certain  cases,  espe- 
cially alcoholic  and  fat  patients,  but  it  may  also  be  employed  during 
the  whole  administration.  The  same  precautions  must  be  observed  as 
in  the  administration  of  chloroform,  especially  as  to  the  free  admission 
of  air  and  the  addition  of  small  quantities  of  the  anesthetic. 

An  excellent  apparatus  for  continuing  anesthesia  in  operations 
about  the  nose,  mouth,  and  throat  is  that  devised  by  Dr.  Thomas  Fille- 
brown,  of  Boston,  and  elaborated  by  his  assistant,  Dr.  M.  F.  Rogers 
(Fig.  189). 

The  principle  of  this  is  to  intensify  the  strength  of  ether-vapor  by 
heating  ether.  Anesthesia  is  induced  in  the  ordinary  way,  and  is  main- 
tained by  playing  a  constant  stream  of  warm  ether-vapor  into  or  over 
the  mouth.  Thus  no  tube  in  the  mouth  nor  catheter  in  the  nose  is 
required,  and  the  use  of  chloroform  is  dispensed  with. 

A  foot-bellows  {b)  forces  air  through  an  afferent  tube  (7)  into  a  bottle 


NITROUS   OX  ID,    ETC. 


465 


(c)  partially  rilled  with  ether.  This  air  is  not  forced  through  the  ether, 
but  merely  over  its  surface,  and,  having  become  laden  with  ether-vapor, 
it  emerges  from  the  bottle  through  an  efferent  tube  (tu),  by  which  it  is 
conducted  to  the  patient. 

The  ether-bottle  is  kept  immersed  in  water  at  1150  F.,  contained 
in  an  inner  aluminum  boiler  (a)  which  is  surrounded  by  an  outer 
aluminum  boiler  (a/)  containing  water  at  1500  F. 


Fig.  ii 


-The  Fillebrown  ether  apparatus  for  keeping  up  stream  of  warm  ether  in 
operations  on  mouth,  throat,  and  nose. 


These  temperatures  are  approximately  maintained  in  prolonged 
operations  by  a  gentle  flame  from  a  shielded  alcohol  lamp  (/),  or  in 
short  operations  by  simply  changing  the  water  in  the  outer  boiler  at 
intervals  of  twenty  to  thirty  minutes. 

Near  the  end  of  the  efferent  tube  is  a  stopcock  (s)  which  regulates 
the  percentages  of  air  and  ether-vapor  delivered  by  the  apparatus.  The 
efferent  tube  terminates  in  a  metal  tube  bent  at  a  right  angle.  A 
second  stopcock  (sr)  regulates  the  air-pressure  from  the  foot-bellows. 

30 


CHAPTER    XV. 
TUMORS. 

The  abnormal  conditions  to  which  the  term  tumor  is  applied  in 
clinical  work  may  be  arranged  in  four  groups:  i.  Connective-tissue 
tumors ;  2.  Epithelial  tumors  ;   3.  Dermoids  ;  4.  Cysts. 

Each  group  contains  several  genera,  and  each  genus  comprises  one 
or  more  species.  The  principle  of  classification  (as  well  as  an  enumer- 
ation of  the  genera)  is  described  with  each  group.  The  definition  of 
each  genus  and  its  species  is  given  separately. 

Before  beginning  the  systematic  description  of  the  various  groups, 
it  is  necessary  to  consider  some  peculiarities  relating  to  the  effects  of 
tumors  upon  the  individual,  which  are  of  the  greatest  clinical  importance. 

In  the  connective-tissue  and  the  epithelial  groups  some  of  the 
genera  display  what  is  known  as  malignancy ;  hence  it  is  customary  to 
speak  of  tumors  as  being  innocent  or  malignant. 

Malignant  Tumors. — These  exhibit  the  following  characters:  I. 
They  infiltrate  the  surrounding  tissues ;  2.  They  infect  adjacent  lymph- 
glands  ;  3.  They  tend  to  recur  after  removal ;  4.  They  become  dissem- 
inated in  distant  organs;  and  5.  They  inevitably  destroy  life. 

Innocent  Tumors.- — These  are,  as  a  rule — 1.  Encapsuled,  and,  when 
diffuse,  do  not  infiltrate ;  2.  They  do  not  infect  the  lymph-glands  ;  3. 
Nor  recur  after  complete  removal;  4.  They  do  not  disseminate;  and  5. 
They  imperil  life  only  when  they  grow  in  the  vicinity  of  vital  organs. 

There  are  two  genera  of  tumors  to  which  the  adjective  malignant  is 
especially  applicable — sarcomata  and  carcinomata. 

It  is  important  to  bear  in  mind  that  innocent  tumors  may,  and  often 
do,  destroy  life.  The  essential  difference  between  an  innocent  and  a 
malignant  tumor  maybe  expressed  thus  :  The  baneful  effects  of  innocent 
tumors  depend  entirely  on  their  environment,  but  malignant  tumors  destroy 
life  zvhatever  their  situation. 

Environment. — it  should  be  borne  in  mind  that  environment 
exercises  an  important  influence  on  the  rapidity  with  which  a  malignant 
tumor  destroys  life.  It  may  be  useful  to  describe  some  examples 
which  will  illustrate  the  importance  of  environment  in  relation  to  the 
destructive  effects  of  tumors  of  all  kinds. 

A  tumor  consisting  of  hyaline  cartilage  (a  chondroma)  is  a  typical 
example  of  a  benign  species.  The  specimen  represented  in  Fig.  190 
arose  in  the  submaxillary  gland  of  a  woman.  When  first  detected  it 
was  as  big  as  a  cherry.  For  many  years  the  tumor  grew  very  slowly 
and  caused  little  inconvenience.  After  forty-four  years  the  mass 
became  so  cumbrous  that  she  submitted  to  operation,  having  attained 
the  age  of  seventy-four.     She  happily  recovered. 

466 


TUMORS. 


467 


FlG.  190. — Chondroma  of  the  submaxillary  gland  which  had  been  slowly  growing  for  forty-four 

years. 


FlG.  191. — Chondroma  of  the  lower  thoracic  vertebrae.  An  outrunner  has  crept  into  the 
neural  canal  through  an  intervertebral  foramen  (Museum  of  St.  Bartholomew's  Hospital, 
London). 


468 


INTERNATIONAL    TEXT-BOON  OF  SURGERY. 


This  tumor  may  be  contrasted  with  the  chondroma  represented  in 
Fig.  191,  growing  from  the  outer  surface  of  a  thoracic  vertebra  and  its 
corresponding  rib.  An  outrunner  from  the  tumor  has  crept  through 
an  intervertebral  foramen  and  spread  upward  and  downward  in  the 

neural  canal ;    it  compressed   the   spinal 
cord,  and  produced  fatal  paraplegia. 

The  baleful  effects  of  environment  are 
strikingly  illustrated  in  the  following 
case :  A  man  thirty-six  years  of  age  was 
found  lying  on  his  back  in  the  street, 
apparently  in  a  fit,  but  he  quickly  died. 
At  the  post-mortem  examination  a  tumor 
no  bigger  than  a  dove's  egg  was  found 
firmly  connected  with  the  windpipe ;  it 
had  so  compressed  the  trachea  as  to 
almost  obliterate  its  channel  (Fig.  192). 
Microscopically,  the  tumor  exhibited  the 
character  of  the  thyroid  gland.  It  may 
have  originated  in  an  accessory  thyroid 
or  even  in  a  parathyroid. 

The  preceding  examples  illustrate  the 
fact  that  when  an  innocent  tumor  causes 
death,  it  is  an  accident  depending  entirely 
on  its  relation  to  vital  organs. 

The  following  illustration  demonstrates 
the  dangerous  character  of  a  malignant 
tumor.  A  man  sixty-five  years  of  age 
had,  as  long  as  he  could  remember,  a 
small  black  patch  1  cm.  (0.4  inch)  in 
diameter  on  the  sole  of  his  foot.  Without 
any  obvious  reason,  this  small  black  area 
increased,  became  slightly  raised,  and  began  to  pulsate.  Shortly  after- 
ward the  lymph-glands  in  the  groin  enlarged  and  formed  a  big  lobu- 
lated  mass,  and  in  the  course  of  a  year  the  man  died  with  secondary 
black  nodules  in  the  lungs,  liver,  kidney,  spleen,  and  skin.  The  urine 
also  contained  black  pigment  (melanin). 

It  is  when  tumors  arise  in  a  situation  such  as  this,  remote  from 
important  organs,  and  yet  destroy  life  in  a  few  months,  that  malignancy 
is  most  significantly  expressed. 

When  a  malignant  tumor  interferes  with  vital  organs,  it  may  cause 
death  very  speedily.  For  instance,  the  lower  half  of  the  esophagus 
with  its  gastric  orifice,  represented  in  Fig.  193,  was  removed  after  death 
from  a  man  forty-six  years  of  age.  He  experienced  slight  irritation  in 
the  throat  while  eating,  and  this  symptom  increased  so  quickly  that  in 
five  months  the  communication  between  the  esophagus  and  the  stomach 
was  obstructed,  and  he  died  of  starvation.  The  tumor  is  a  carcinoma, 
shaped  like  a  cotton  bobbin.  The  narrow  part  of  the  tumor  was  gripped 
by  the  esophageal  opening  of  the  diaphragm,  and  the  broad  ends  pro- 
jected, one  above  and  one  below  this  muscle. 

One  of  the  most  striking  facts  in  connection  with  malignant  tumors 
is  the  insidious  way  in  which  they  will  involve  organs,  and  yet  give 


FlG.  192. — Encapsulated  tumor 
which  compressed  the  trachea  and 
caused  death. 


TUMORS. 


469 


Mucous  mem- 
brane. 


Circular 

muscle-fibers. 


Longitudinal 
muscle-fibers. 


rise  to  few  signs  until  they  interfere  with  its  function.     Many  malignant 
tumors  arising  in  the  pelvic  organs  of  men  and  women  run  a  rapidly 
fatal  course,  because  they  implicate  the  bladder  and  the  vesical  ends  of 
the  ureters,  and  set  up  renal 
disturbance  and  uremia. 

It  is  a  marked  feature  of 
malignant  tumors  that  when 
the  primary  tumor  implicates 
a  vital  organ,  it  may  destroy 
life  before  there  has  been  time 
for  dissemination  to  occur; 
when  the  environment  is  un- 
favorable, then  death  is  often 
induced  by  secondary  nod- 
ules occupying  important 
organs, such  as  the  lung,  liver, 
brain,  etc. 

Innocent  tumors  differ 
from  malignant  ones  in  the- 
fact  that  they  may  occur  in 
multiples.  It  is  common 
enough  to  find  5,  10,  and 
even  20  subcutaneous  lipo- 
mata  on  an  individual.  Fifty 
and  even  1000  neuromata 
have  been  counted  on  the 
nerves  of  one  man.  Ten 
or  100  fibroids  may  grow 
concurrently  in  a  uterus,  and 
3  or  more  nevi  have  often 
been  observed  on  the  skin 
of  an  infant.  Chondromata, 
osteomata,  and  odontomata 
occur  in  multiples  ;  while  ova- 
rian dermoids  and  adenomata 
are  frequently  bilateral. 

Adenomata  are  often  found 
in  both  mamma;,  and  two  or 

three  sometimes  grow  concurrently  in  the  same  breast.  Multiple 
adenomata  are  by  no  means  rare  in  the  thyroid,  prostate,  and  liver. 
Psammomata,  though  rare  tumors,  often  occur  bilaterally  in  connec- 
tion with  the  choroid  plexuses  of  the  brain. 

It  is,  however,  rare  to  find  two  primary  sarcomata  save  in  paired 
organs.  Bilateral  sarcomata  of  the  kidney,  retina,  and  ovary  of  infants 
are  common.  In  one  interesting  case  a  kidney  of  an  infant  was  excised 
for  sarcoma;  four  and  a  half  years  later  a  sarcoma  arose  in  the  remain- 
ing kidney  and  destroyed  the  patient  (Abbe).  A  similar  condition  has 
been  observed  in  connection  with  the  testis.  One  was  removed  from  a 
man  of  seventy  years  for  lymphosarcoma ;  the  disease  subsequently 
arose  in  the  opposite  testis  and  destroyed  the  patient  (Hutchinson). 

The  occurrence  of  two  primary  carcinomata  in  an  individual  is  exces- 


Carcinoma. 


Diaphragm. 


FIG. 


-Ml** 


193. — Lower  half  of  an  esophagus.     Its  gastric 
orifice  is  obstructed  by  a  carcinoma. 


47Q 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


sively  rare,  except  in  the  peculiar  form  of  skin-cancer  known  in  England 
as  rodent  ulcer  (see  page  496). 

The  concurrence  of  primary  carcinomata,  even  in  bilateral  organs — 
e.  g.,  the  mammae — has  rarely  been  substantiated  by  adequate  micro- 
scopical evidence. 

It  is  excessively  rare  to  find  two  primary  carcinomata  of  different 
genera  attacking  the  same  person.  My  own  experience  is  limited  to 
one  case.  Primary  mammary  carcinoma  occurred  in  a  lady  of  fifty- 
eight  years  ;  the  tumor  was  removed,  and  its  nature  determined  by  the 
microscope.  Two  years  later  a  typical  carcinoma  arose  in  the  mucous 
membrane  of  the  rectum  ;  it  was  successfully  excised.  Of  all  the  species 
of  carcinoma,  the  mammary  and  uterine  are  most  common,  but  no 
instance  of  their  concurrence  is  recorded. 

The  coexistence  in  the  same  person  of  two  genera  of  innocent 
tumors  is  well  known — indeed,  is  almost  a  matter  of  daily  observation, 
uterine  myomata  and  ovarian  dermoids,  lipomata  and  sequestration 
dermoids,  chondromata  and  osteomata,  etc.,  being  frequent  combinations. 
An  individual  may  have  one  or  more  innocent  tumors  for  many 
years,  and  then  a  carcinoma  may  arise,  sometimes  in  an  organ  already 

occupied  by  a  tumor.  For  example, 
the  uterus  may  be  the  seat  of  a  large 
myoma,  and  carcinoma  may  subse- 
quently arise  in  the  cervical  endo- 
metrium. 

Mammary  carcinoma  and  ovarian 
adenoma  occasionally  grow  concur- 
rently ;  or  cancer  may  arise  in  the 
mamma  a  year  or  more  after  the  re- 
moval of  a  unilateral  or  bilateral  ova- 
rian tumor. 

Two  examples  of  the  coexistence 
of  pyloric  cancer  and  ovarian  adenoma 
have  come  under  my  observation,  and 
on  one  occasion  I  removed  a  myxoma 
from  the  lower  cervical  nerves  and  a 
cancerous  breast  from  the  same  patient 
on  the  same  day.  A  very  rare  com- 
bination, observed  by  Hutchinson,  is 
an  adenoma  of  the  mamma  embedded 
in  a  mammary  carcinoma.  The  woman 
was  forty-six  years  of  age,  and  had 
noticed  the  lump  in  her  breast  for 
twenty  years. 

An  important  feature  of  innocent 
tumors  is  the  existence  in  most  of 
them  of  a  distinct  capsule  which  iso- 
lates them  from  the  surrounding  tissues;  those  which  are  "diffuse" 
differ  from  malignant  tumors  in  that  they  do  not  infiltrate.  This  dis- 
tinction between  an  encapsuled  and  an  infiltrating  tumor  is  shown  in 
Fig.  194;  the  isolation  of  the  adenoma  stands  in  striking  contrast  to 
the  indefiniteness  of  the  carcinoma. 


Fig.  194. — A  mamma  in  section,  show- 
ing an  adenoma  (b)  surrounded  by  carci- 
noma (a)  (Museum  of  the  Royal  College 
of  Surgeons,  London). 


CONNECTIVE-TISSUE    TUMORS.  47 1 

The  infiltrating  propensities  of  malignant  tumors  explain  in  part  the 
frequency  and  rapidity  with  which  they  sometimes  recur  after  removal, 
for  in  attempting  its  extirpation,  the  surgeon,  unable  to  define  their  limits, 
leaves  portions  of  the  tumors,  and  as  the  life  of  these  outlying  fragments 
is  uninfluenced  by  the  removal  of  the  main  mass,  they  continue  to  grow. 

I/ymph-gland  Infection. — This  is  a  very  remarkable  feature  in 
connection  with  carcinoma  and  cutaneous  melanomata.  The  cells 
from  the  primary  tumor  are  conveyed  by  the  lymphatics  to  the  corre- 
sponding lymph-glands,  which  enlarge  and  often  form  masses  exceed- 
ing in  size  the  primary  tumor.  When  the  lymph-glands  thus  become 
infected,  the  removal  of  the  primary  tumor  in  no  way  influences  them, 
for  the  carcinomatous  elements  in  the  lymph-glands  continue  to  grow 
and  destroy  life  as  surely  as  if  the  primary  tumor  had  been  allowed 
to  persist. 

Dissemination. — The  most  extraordinary  fact  in  regard  to  malig- 
nant tumors  is  their  tendency  to  reproduce  themselves  in  distant 
organs.  This  dissemination  is  effected  by  lymphatics  and  by  veins. 
The  products  of  this  process  are  known  as  secondary  nodules,  and 
they  agree  histologically  with  the  primary  tumor.  In  some  cases  the 
identity  is  so  complete  that  an  experienced  oncologist  can  often  tell 
from  the  microscopical  structure  of  a  secondary  nodule  the  situation  of 
the  primary  tumor.  Thus,  a  patient  had  many  secondary  nodules  in  his 
skin ;  the  primary  seat  of  the  disease  had  not  been  detected ;  one  of 
the  nodules  was  excised  and  found  to  contain  glands  such  as  occur  in 
the  stomach  and  intestine.  When  the  man  died,  a  carcinoma  was  found 
at  the  pyloric  end  of  the  stomach. 

I.  CONNECTIVE-TISSUE  TUMORS. 

Virchow  (1863)  demonstrated  that  all  the  tissues  found  in  tumors 
have  a  physiological  prototype,  and  as  complete  ignorance  exists  as  to 
the  pathogenesis  or  cause  of  tumors,  it  is  necessary  for  the  purpose  of 
classification  to  use  their  structural  (histologic)  characters  as  a  base. 
Hence  it  is  customary  to  classify  the  tumors  of  this  group  into  genera 
according  to  the  tissue  which  preponderates  : 


I. 

Lipomata. 

8. 

Neuromata. 

2. 

Chondromata. 

9- 

Angiomata. 

3- 

Osteomata. 

10. 

Lymphangiomata, 

4- 

Odontomata. 

1 1. 

Myomata. 

5- 

Fibromata. 

12. 

Myelomata. 

6. 

7- 

Myxomata. 
Gliomata. 

13- 

Sarcomata. 

Before  discussing  each  genus,  it  will  be  useful  to  point  out  that 
Virchow's  great  generalization  has  been  so  well  established  that  if  the 
student  were  asked  to  enumerate  the  primary  tumors  likely  to  occur 
in  a  particular  organ,  it  would  be  merely  necessary  to  make  a  list  of 
the  various  structures  and  tissues  composing  it  in  order  to  answer. 
To  put  the  matter  briefly,  it  may  be  said  that  the  structure  and  embry- 
ology of  an  organ  are  guides  to  the  tumors  which  may  arise  therein. 


472 


INTERNATIONAL    TEXT-BOOK   OE  SURGERY. 


_   Epiphysis. 


Epiphyseal 
line. 

Cancellous 
tissue  with 
red     mar- 
row. 


Tibia. 


Periosteum. 


Take,  for  instance,  the  tibia  of  a  child  of  ten  years  :  it  contains  carti- 
lage, bone,  periosteum,  fat,  and  red  marrow.  Each  of  these  tissues 
may  give  rise  to  a  tumor.     Thus  the  epiphyseal  cartilage  may  be  the 

source  of  a  chondroma  or  an 
osteoma ;  the  periosteum  fur- 
nishes sarcomata  and  occasion- 
ally lipomata ;  and  myelomata 
arise  in  the  red  marrow.  Epi- 
thelial tumors — cancers — do  not 
arise  primarily  in  bone,  as  it  has 
no  epithelium,  but  they  often 
occur  as  secondary  deposits. 

The  doctrine  of  tissue-proto- 
types is  admirably  illustrated  in 
the  case  of  the  kidney.  This 
organ  is  a  compound  gland  con- 
sisting of  a  multitude  of  com- 
plicated (uriniferous)  tubules, 
lined  with  epithelium.  These 
tubules  open  into  a  dilatation 
(the  pelvis)  at  the  upper  end  of 
the  ureter.  The  renal  pelvis 
with  its  recesses  (infundibula) 
consists  of  unstriped  muscle- 
tissue,  lined  with  epithelium. 
The  sinus  of  the  kidney,  besides 
accommodating  the  ureter,  renal 
vessels,  and  nerves,  is  occupied 
by  connective  tissue.  In  addi- 
tion, small  detached  adrenals  are 
occasionally  found  embedded  in 
the  renal  cortex  immediately  be- 
neath the  capsule. 

Taking  our  knowledge  of  the 
structure  of  the  kidney  into  ac- 
count, we  should  expect  to  find 
tumors  arising  in  it  which  could 
be  accredited  to  the  following 
genera :  Adenoma  and  carcinoma 
originating  in  the  cortex ;  sar- 
coma growing  from  the  connec- 
tive tissue  of  the  sinus  ;  myomata 
starting  from  the  pelvis,  and  papillomata  from  its  lining  epithelium  ; 
and,  lastly,  tumors  from  the  accessory  adrenals  lodged  in  its  cortex. 
So  far,  a  true  renal  adenoma  has  yet  to  be  demonstrated,  but  the 
remaining  genera  have  been  repeatedly  observed. 

Although  our  knowledge  of  the  intimate  structure  of  tumors,  thanks 
to  differential  staining  methods,  is  now  sufficient  to  enable  us  to  indicate 
from  the  structure  of  an  organ  the  genera  of  tumors  to  which  it  may  be 
liable,  nevertheless  the  most  careful  study  of  the  minute  structure  of  such 
organs  as  the  salivary  glands  would  not  lead  us  to  suspect  their  liability 


Tumor. 


BERJEAU 


-Sarcoma  of  the  tibia  in  a  girl,  in 
section. 


CONNECTIVE-TISSUE    TUMORS. 


473 


to  purechondromata;  and  it  is  "passing  strange"  that  they  should  occur 
in  the  parotid,  submaxillary,  and  lacrimal  glands,  and  yet  be  unknown  in 
the  pancreas.  What  oncologist,  merely  from  studying  the  histology 
of  a  normal  ovary,  would  suspect  that  it  would  be  the  point  of  origin  of 
a  dermoid  ?  It  is  like  studying  the  fauna  of  a  country.  For  instance, 
who  suspected,  until  Australia  was  discovered,  the  existence  of  extra- 
ordinary mammals  like  kangaroos  and  duck  moles  ?  But  knowledge 
gained  from  observation  enables  us  to  state  that  gliomata  do  not  arise 
in  bone,  nor  myomata  in  the  brain,  nor  dermoids  in  the  spleen,  liver,  or 
kidney,  with  the  same  certainty  that  we  assert  that  at  the  present 
period  of  our  planet's  history  lions  do  not  sport  about  the  ice-fields 
of  Greenland,  nor  humming-birds  flit  about  the  flower-beds  of  Hyde 
Park. 

It  is,  however,  necessary  to  point  out  that,  although  the  tissues  of 
an  organ  determine  the  species  of  tumors  to  which  it  may  be  liable, 
their  relative  frequency  can  be  gathered  only  from  observation. 

The  liability  of  organs  to  tumors  composed  of  similar  tissues  is  a 
very  curious  matter.  The  heart  is  with  excessive  rarity  occupied  by 
a  tumor :  on  the  other  hand,  the  uterus,  a  muscular  organ,  is  with 
extreme  frequency  the  seat  of  myomata.  The  liability  of  bones  to 
sarcomata  is  proverbial,  yet  a  sarcoma  of  a  voluntary  muscle  is  a 
rarity.  A  primary  tumor  of  the  lung  is  regarded  as  a  phenomenon, 
but  it  is  common  enough  in  the  brain.  It  is  also  mysterious  why  a 
sarcoma  of  the  shaft  of  the  femur  or  of  the  humerus  should  be  the 
deadliest  of  all  tumors.  These  and  many  kindred  questions  indicate 
profound  imperfection  in  our  knowledge. 

I/ipOtnata  [Fatty  Tumors). — These  tumors  are  composed  of  fa<\ 
The  genus  consists  of  a  single  species.  They  occur  in  connection  with 
almost  every  organ  of  the  body. 

Subcutaneous  Lipomata. — These  occur  as  irregularly  lobulated, 
encapsuled  tumors  in  the  subcutaneous  fat.  They  are  usually  movable 
within  their  capsules,  and  the  overlying  skin  is  puckered,  especially 
when  an  attempt  is  made  to  raise  it  from  the  underlying  tumor. 

Lipomata  vary  in  size ;  some  may  have  a  diameter  of  2  cm. 
(f-  inch),  whilst  others  have  a  circumference  of  a  meter  (39.37  in.). 
In  the  majority  of  cases  1  tumor  is  present;  in  others  10,  20,  or  more 
coexist.  The  favorite  situation  is  the  trunk  and  trunk-end  of  the 
limbs,  but  they  arise  on  the  face,  scalp,  palm,  sole  (Fig.  196),  fingers, 
and  scrotum.     Occasionally  they  are  pedunculated. 

There  is  a  variety,  most  frequently  seen  on  the  arms  and  thighs, 
occasionally  on  the  trunk,  and  rarely  exceeding  the  dimensions  of  a 
filbert  nut,  which  occurs  in  multiples,  and,  as  they  are  often  painful, 
simulate  neuromata.  Irregular  non-encapsuled  masses  of  fat  are  some- 
times seen  on  the  neck,  axillae,  and  groins  ;  they  are  known  as  "  diffuse 
lipomata."  Fatty  tumors  that  have  existed  many  years  sometimes 
calcify,  the  earthy  salts  being  deposited  in  the  fibrous  septa  of  the 
tumor.  This  change  may  affect  pedunculated  as  well  as  sessile  lipo- 
mata ;  saponification  occasionally  occurs   in  old  lipomata. 

Very  vascular  lipomata  are  sometimes  called  nevolipomata :  they 
are  met  with  on  the  face  and  on  the  periosteum  of  long  bones  in  situa- 
tions where  it  is  subcutaneous. 


474 


INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 


Subserous  Lipomata. — The  peritoneum,  like  the  skin,  rests  upon  a 
bed  of  fat.  Lipomata  of  enormous  dimensions  arise  sometimes  in  this 
subserous  layer,  and,  like  the  subcutaneous  species,  they  may  be 
sessile  or  pedunculated.  Fatty  tumors  sometimes  arise  in  the  redup- 
lications of  the  peritoneum,  such  as  the  omentum,  mesentery,  and 
mesometrium.  When  they  drag  upon  the  peritoneum  in  the  neigh- 
borhood of  the  inguinal  rings,  the  crural  canal,  or  adventitious  opening 
in  the  linea  alba  or  diaphragm,  they  produce  finger-like  pouches  known 
as  fatty  herniae.  These  are  especially  common  in  the  neighborhood  of 
the  umbilicus.     Pedunculated  subserous   lipomata  are   usually  associ- 


FlG.  196. — Lipoma  of  the  sole  which  had  existed  for  thirty  years.     The  foot  was  amputated  by 
Percival  Pott  (Museum  of  St.  Bartholomew's  Hospital,  London). 

ated  with  the  colon  ;  they  are  usually  exaggerated  epiploic  appendages. 
This  species  of  lipomata  sometimes  arises  in  the  spermatic  cord,  and 
assumes  a  characteristic  elongated,  ovoid  shape. 

Subsynovial  Lipomata. — Many  synovial  membranes  have  fat  in 
their  deeper  layers.  This  may  project  into  the  joint,  and,  becoming 
pedunculated,  form  subsynovial  lipomata.  Usually  many — 50  to  100 
— are  present.     Muller  termed  the  condition   "  lipoma  arborescens." 

Submucous  lipomata  rarely  attain  a  large  size.  They  have  been 
found  in  the  conjunctiva,  lips,  pharynx,  larynx,  stomach,  small  intestine, 
colon,  and  rectum.     They  may  be  sessile  or  stalked. 

Intermuscular  Lipomata. — The  connective  tissue  of  intermuscular 
septa  is  provided  with  fat  and  is  the  source  of  fatty  tumors,  sometimes 
of  large  size.     They  occur  equally  in  the  trunk  and  limbs. 

Intramuscular  Lipomata. — Many  examples  of  fatty  tumors  occur- 
ring in    muscles   have   been  recorded.     They  have  been  found  in  the 


CONNECTIVE-TISSUE    TUMORS.  475 

biceps,  deltoid,  complexus,  the  cardiac  septum,  and  the  rectus 
abdominis. 

Periosteal  lipomata  arise  from  the  periosteum  of  bones,  and  nearly 
always  contain  tracts  of  striped  muscle-tissue.  They  have  been 
observed  on  the  scapula,  innominate  bone,  clavicle,  humerus,  radius, 
ulna,  femur,  tibia,  fibula,  cervical  vertebrae,  and  the  frontal  bone,  and 
they  often  simulate  periosteal  sarcomata. 

Meningeal  Lipomata. — Fatty  tumors  occur  on  the  outer  or  inner 
surface  of  the  spinal  dura  mater.  The  extradural  variety  often  over- 
lies the  sac  of  a  spina  bifida.  Intradural  lipomata  may  contain  tracts 
of  striped  muscle-tissue ;  occasionally  they  are  associated  with  a  masked 
spina  bifida.  Fatty  tumors  growing  from  the  sheath  of  nerves  are 
sometimes  called  neurolipomata. 

Chrondomata  [Cartilage  Tumors). — These  tumors  are  composed 
of  hyaline  cartilage.  The  genus  contains  three  species  :  I.  Chondro- 
mata ;   2.  Ecchondroses ;  3.  Loose  cartilages  in  joints. 

Chondromata. — In  the  most  typical  condition  this  species  is  met 
with  in  the  long  bones  of  the  limbs,  especially  those  of  the  hand.  They 
arise  in  connection  with  epiphyseal  cartilages  ;  hence  chondromata  are 
more  common  in  children  and  in  early  adult  life.  They  often  occur  in 
multiples,  but  solitary  examples  are  not  rare.  Those  who  have  had 
rickets  are  especially  prone  to  develop  chondromata,  and  the  tumor- 
tissue  resembles  the  bluish,  translucent  cartilage  so  characteristic  of  the 
rickety  epiphyseal  line.  Chondromata  are  encapsuled,  painless,  grow 
slowly,  and  are  very  prone  to  mucoid  degeneration  ;  they  frequently 
ossify.  Tumors  composed  of  pure  hyaline  cartilage  occur  in  the 
parotid,  submaxillary,  and  lacrimal  glands.  (See  Chondrifying  Sarcoma, 
page  486.) 

Ecchondroses  are  local  outgrowths  of  cartilages,  and  occur  along 
the  edges  of  articular  cartilages,  especially  of  the  knee-joint.  They 
are  common  on  the  triangular  cartilage  of  the  nose,  and  occasionally 
spring  from  the  cartilages  of  the  larynx. 

Loose  Cartilages  of  Joints — The  pedunculated  fringes  hanging 
from  the  synovial  membranes  of  joints  often  chondrify,  and,  when  they 
become  detached,  give  rise  to  one  variety  of  loose  body  in  the  joint. 

Osteomata  {Bony  Tumors). — An  osteoma  may  be  defined  as  an 
ossifying  chondroma.  The  genus  contains  two  species:  1.  Compact 
or  ivory  osteoma  ;   2.  Cancellous  osteoma. 

Compact  osteomata  are  structurally  identical  with  the  compact 
tissue  of  the  shaft  of  a  long  bone.  Often  their  substance  is  as  dense 
as  that  of  the  petrosal.  They  occur  most  frequently  on  the  bones  of 
the  skull,  especially  from  the  walls  of  the  frontal  sinus,  the  osseous 
walls  of  the  external  auditory  meatus,  the  mastoid  process,  and  the 
angle  of  the  mandible.     This  species  is   usually  sessile. 

Cancellous  osteomata  resemble  in  structure  the  cancellous  tissue 
of  bone.  They  usually  arise  in  the  neighborhood  of  the  epiphyseal 
lines,  and,  when  growing,  are  capped  with  cartilage,  which  bears  the 
same  relation  to  the  tumor  that  an  epiphyseal  line  bears  to  a  long  bone. 
These  tumors  may  be  sessile  or  pedunculated.  When  situated  at  the 
distal  end  of  the  radius  or  tibia,  they  are  deeply  channelled  by  the  flexor 
and  extensor  tendons.     When  projecting  near  the  skin,  the  summit  is 


476  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

often  surmounted  by  a  bursa.     This  species  may  be  single ;  often  they 
are  multiple. 

Exostoses. — Often  all  bony  outgrowths,  including  osteomata,  are 
vaguely  classed  as  exostoses.  Under  the  term  exostosis  are  included 
ossification  of  tendons  at  their  attachments,  the  subungual  exostosis, 
and  calcified  inflammatory  exudations.  An  exostosis  is  not  a  true 
tumor. 

Odontotnes  {Tooth  Tumors). — These  are  tumors  composed  of 
dental  tissues  in  varying  proportions  and  different  degrees  of  develop- 
ment, arising  from  teeth-germs  or  teeth  still  in  the  process  of  growth. 
The  species,  determined  according  to  the  part  of  the  tooth-germ  con- 
cerned in  their  formation,  are :  I.  Epithelial  odontome;  2.  Follicular 
odontome ;  3.  Fibrous  odontome;  4.  Cementome;  5.  Compound 
follicular  odontome  ;  6.  Radicular  odontome  ;  7.  Composite  odontome. 

Epithelial  odontomes  arise  from  the  enamel  organ,  and  occur  as 
encapsuled  tumors  in  the  jaws.  On  section  they  are  made  up  of  con- 
geries of  cysts  of  various  shapes  and  sizes.  Histologically  they  con- 
sist of  branching  and  anastomosing  columns  of  epithelium  which  con- 
tain tissue  resembling  the  stratum  intermedium  of  an  enamel  organ. 

Follicular  Odontomes  {Dentigerous  Cyst  of  older  writers). — This 
species  is  usually  associated  with  the  permanent  teeth.  They  arise  in 
this  way :  A  tooth  is  retained,  and  the  wall  of  the  follicle  becomes 
greatly  thickened  and  distended  with  fluid.  The  tooth  may  be  loose 
in  the  sac,  sometimes  inverted,  or  its  root  may  be  truncated  (incom- 
plete). As  a  rule,  a  single  odontome  is  present,  but  2  and  even  4  may 
coexist. 

Fibrous  Odontomes — Every  tooth  before  eruption  is  enclosed  in  a 
fibrous  capsule — the  tooth-sac.  This  sac  may  become  so  thick  that 
the  tooth  is  embedded  and  remains  non-erupted.  Sometimes  it  is  rep- 
resented as  a  denticle.  This  species  has  often  been  described  as  mye- 
loid sarcoma.     It  occurs  most  frequently  in  rickety  children. 

Cementomes  are  met  with  in  ruminants ;  they  are  rarely  observed 
in  man. 

Compound  follicular  odontomes  consist  of  fibrous  tumors  with 
numerous  denticles  embedded  in  their  substance,  which  erupt  from 
time  to  time. 

Radicular  odontomes  arise  after  the  crown  of  the  tooth  is  com- 
pleted, and  are  formed  from  the  tooth-papilla.  They  consist  of  dentine 
and  cementum  in  varying  proportions. 

Composite  odontomes  are  due  to  disorder  of  the  whole  tooth-germ  ; 
they  consist  of  enamel,  dentine,  and  cementum  irregularly  intermixed. 

Odontomes  occur  in  the  upper  as  well  as  the  lower  jaw ;  but  all  the 
species  attain  a  far  larger  size  in  the  maxilla  than  in  the  mandible,  for 
they  are  able  to  invade  the  antrum,  and  for  a  time  there  is  less  restric- 
tion to  their  growth. 

Fibromata. — These  are  tumors  composed  of  wavy  bundles  of  dense 
fibrous  tissue.  The  bundles  consist  of  long,  slender,  fusiform  cells, 
closely  packed  together  and  frequently  arranged  in  whorls  ;  the  arteries 
of  the  tumor  frequently  traverse  the  centers  of  the  vortices.  Simple 
fibromata  occur  in  the  following  situations  :  On  the  gums  (epulis),  in 
the  ovary,  uterus  (fibroids),   on  nerves  (neuromata),   and  as  the  tiny 


CONNECTIVE-TISSUE    TUMORS.  477 

nodules  in  the  skin  known  as  painful  subcutaneous  tubercle.  It  is  a 
matter  of  great  difficulty  to  determine  histologically  between  some 
fibromata  and  slowly  growing  spindle-celled  sarcomata. 

Myxomata. — These  tumors  are  composed  of  tissue  identical  with 
that  which  surrounds  the  vessels  of  the  umbilical  cord. 

The  genus  contains  a  single  species — myxoma.  Tumors  composed 
almost  entirely  of  myxomatous  tissue  are  very  rare,  and,  when  cut  into, 
resemble  a  mass  of  trembling  jelly,  from  which  a  quantity  of  straw- 
colored  fluid  drains  away.  Microscopically,  myxomatous  tissue  consists 
of  cells  with  long,  slender,  delicate  processes. 

Myxomata  are  very  rare,  but  many  tumors  contain  tracts  of  myxo- 
matous tissue  as  a  secondary  change.  This  is  especially  the  case  with 
chondromata,  fibromata,  myomata,  and  sarcomata.  The  characters  of 
myxomata  may  be  studied  in  the  common  nasal  polypi.  These  are 
edematous  pendulous  processes  of  mucous  membrane. 

Gliomata. — The  tumors  of  this  genus  are  composed  of  the  deli- 
cate connective  tissue  known  as  neuroglia.  It  contains  a  single  species 
— glioma. 

Gliomata  occur  only  in  the  central  nervous  system  as  tumors  imper- 
fectly demarcated  from  the  surrounding  tissue.  A  glioma  may  consist 
of  translucent  tissue  of  the  consistence  of  vitreous  humor,  or  it  may  be 
as  firm  as  the  cerebral  cortex.  The  tumors  consist  of  cells  furnished 
with  delicate  ramifying  processes :  the  cells  contain  one  or  more 
nuclei.  Gliomata  are  quite  often  very  vascular,  and  in  some  the  vessels 
are  so  numerous  that  they  have  been  described  as  cerebral  angiomata 
or  angiosarcomata. 

Gliomata  are,  as  a  rule,  solitary  tumors,  and  do  not  disseminate. 
They  are  twenty  times  more  common  in  the  brain  than  in  the  spinal 
cord. 

Neuromata  and  Neurofibromatosis. — The  tumors  of  nerves 
formerly  grouped  together  as  neuromata  by  surgeons  have  in  recent 
years  received  careful  attention  from  pathologists,  which  has  led  them 
to  include  some  remarkable  and  apparently  diverse  conditions  under 
the  term  neuromata. 

The  nerve-centers — brain  and  spinal  cord — the  nerve-trunks  and 
their  terminal  twigs,  the  sympathetic  nerve-cords  and  their  ganglia,  are 
all  pervaded  with  connective  tissue  of  varying  degree  of  texture,  which 
is  coarse  in  the  great  sciatic  nerve,  but  of  extreme  delicacy  in  the  retina 
and  brain.  The  common  and  familiar  swelling;  to  which  the  term  neu- 
roma  is  usually  applied  is  an  ovoid  encapsulated  tumor  composed  of 
tissue  identical  with  that  of  the  nerve-sheath.  One  neuroma  or  many 
may  occur  upon  a  nerve  or  nerve-root :  some  are  no  bigger  than  hemp- 
seeds,  and  one  of  these  small  nodules  on  the  terminal  twig  of  a  cutane- 
ous nerve  will  give  rise  to  such  pain  when  touched  that  it  is  called  in 
consequence  a  "  painful  subcutaneous  tubercle."  The  common  solitary 
neuroma  has  received  a  variety  of  names  depending  on  its  minute 
structure,  such  as  myxoma,  myxofibroma,  fibroma,  and  so  on,  the 
variety  of  texture  depending  on  degenerative  changes  in  the  tumor 
tissue. 

It  has  been  definitely  proved  that  tumors  occur  in  the  skin,  some- 
times in  great  numbers,  and  resemble  lipomata,  but  on  careful  examin- 


478 


INTERNATIONAL    TEXT-BOOK   OE  SURGERY. 


ation  they  have  been  found  to  contain  nerve  elements  and  in  particular 
nerve-cells.  These  are  known  as  ganglionic  neuromata,  and  it  is  sup- 
pi  >sed  that  they  arise  on  the  terminal  twigs  of  the  sympathetic  nerves 
distributed  to  the  cutaneous  twigs  of  the  arteries. 

It  has  been  known  for  many  years  that  individuals  occasionally 
come  under  observation  with  tracts  of  skin  excessively  developed  in 
the  form  of  overlapping  folds,  and  these  may  occur  on  the  trunk,  head, 
or  limbs.  This  condition  is  known  under  a  variety  of  names,  but  that 
accepted  by  the  most  recent  writers  is  molluscum  fibrosum  (Fig.  197). 
This  disease  may  manifest  itself  in  the  form  ot  a  multitude  of  discrete 
nodules  on  the  skin,  varying  in  size  from  a  mustard  seed  to  a  billiard 
ball.  Recklinghausen,  who  studied  the  histology  of  these  molluscum 
nodules  with  great  care,  has  expressed  the  opinion  that  they  arise  from 
the  terminal  twigs  of  the  cutaneous  nerves.  These  molluscum  nodules 
also  occur  in  association  with  a  multitude  of  irregular  swellings  on  the 


fiwt<P*h'3r- 

FIG.  197—  Pedunculated  molluscum  fibrosum  which  grew  from  the  mammary  areola  (Museum 
of  Middlesex  Hospital,  London). 


nerves,  and  in  one  remarkable  case  2000  tumors  were  observed 
on  the  skin  and  nerve-trunks  (Smith).  It  is  also  an  important  fact 
that  although  neuromata,  molluscum  nodules,  and  molluscum  folds 
occur  on  separate  individuals,  nevertheless  all  three  conditions  some- 
times occur  on  the  same  patient.  It  is  now  usual  to  speak  of  the 
generalized  form  of  the  disease  as  neurofibromatosis,  and  an  important 
feature  of  the  disease  is  the  liability  of  the  patients  to  sarcoma,  which 
may  develop  primarily,  or  arise  as  a  malignant  change  in  a  molluscum 
nodule  which  has  existed  many  years. 

Pathologists  have  long  been  familiar  with  a  peculiar  overgrowth  of 
delicate  connective  tissue  of  the  brain  and  spinal  cord  under  the  name 
of  glioma;  this  appears  as  a  translucent  swelling,  imperfectly  demar- 
cated from  the  surrounding  tissue,  and,  as  a  rule,  has  little  more  con- 
sistency than  vitreous  humor ;  microscopically  it  has  all  the  characters 
of  neuroglia.      It  is  an  extraordinary  fact  that  the  connective  tissue, 


CONNECTIVE-TISSUE    TUMORS.  479 

especially  the  endoneurium  of  nerves,  is  liable  to  a  similar  change, 
which  may  be  and  is  usually  limited  to  a  particular  nerve  and  its 
branches.  The  effect  upon  the  nerve  is  striking,  for  it  becomes  thick- 
ened, elongated,  and  tortuous,  and  when  cut  across  the  nerve-sheath  is 
found  filled  with  gelatinous  tissue  and  appears  like  the  cut  surface  of 
an  umbilical  cord.  The  term  plexiform  neuroma  is  applied  to  this 
condition,  and  it  is  especially  liable  to  arise  in  nerves  associated  with 
congenital  tracts  of  hairy  and  pigmented  skin  (hairy  mole). 

Angiomata. — These  are  tumors  composed  of  an  abnormal  forma- 
tion of  blood-vessels.  The  genus  contains  three  species — simple  nevus  ; 
cavernous  nevus  ;  plexiform  angioma. 

Simple  Nevus. — Of  this  species  there  are  three  varieties.  A  nevus 
may  appear  as  a  superficial  pink  or  deep-blue  discoloration  of  the  skin, 
known  as  "port-wine  stain;"  it  may  involve  an  area  of  skin  2  cm. 
(f  inch)  square,  or  a  large  part  of  the  face,  half  the  trunk,  or  even  a 
whole  limb. 

More  frequently  the  nevus  appears  in  the  form  termed  telangiectasis. 
This  consists  of  an  abnormal  collection  of  arterioles  or  venules  in  the 
skin,  the  subcutaneous  and  subperitoneal  tissue,  less  frequently  in 
mucous  membrane.  All  examples  of  telangiectasis  contain  arterioles, 
venules,  lymphatics,  and  fat  in  varying  proportions.  When  arterioles 
preponderate,  the  nevus  is  red ;  when  venules  are  in  excess,  it  is  blue ; 
when  lymphatics  are  most  numerous,  it  may  be  light  pink  or  nearly 
colorless ;  this  is  a  lymphangioma  (see  page  480).  Some  venous 
nevi  are  encapsuled,  and  simulate  dermoids  and  cystic  tumors.  Many 
encapsuled  nevi  contain  a  large  proportion  of  fat,  and  are  then  termed 
ncvolipomata. 

Cavernous  Nevi. — These  are  in  structure  like  the  vascular  portions 
of  the  corpus  cavernosum  and  corpus  spongiosum,  and  are  made  up  of 
venous  and  arterial  channels  and  sinuses  communicating  with  neighbor- 
ing arteries  and  veins.  A  cavernous  nevus  sometimes  arises  from  the 
transformation  of  a  telangiectasis.  This  species  of  nevus  is  red  or  blue, 
according  to  the  predominance  of  arterial  or  venous  channels. 

Cavernous  nevi,  like  simple  ones,  as  a  rule,  are  either  congenital  or 
appear  in  early  infancy.  Many  nevi  disappear ;  others  when  first  seen 
are  small  and  inconspicuous,  then  rapidly  grow,  and  in  a  few  months 
form  conspicuous  tumors.  Cavernous  nevi  have  the  same  distribution 
as  the  simple  species.  Cavernous  nevi,  like  the  telangiectactic  variety, 
have  been  met  with  in  the  subperitoneal  tissue,  and  especially  in  con- 
nection with  the  serous  surface  of  the  liver.  The  central  parts  of  a 
large  cavernous  nevus  sometimes  degenerate  and  are  occupied  by  loculi 
filled  with  lymph. 

Plexiform  Angioma. — This  species  consists  of  a  number  of  blood- 
vessels arranged  more  or  less  parallel  with  each  other.  Many  pursue  a 
tortuous  course.  In  some  tumors  arteries  alone  are  present,  in  others 
there  are  veins  and  arteries.  Plexiform  angiomata  are  rare;  they  occur 
most  commonly  on  the  scalp  and  upper  limb.  Plexiform  angiomata 
have  a  physiological  prototype  in  the  retia  mirabilia,  which  occur 
naturally  in  the  intercostal  spaces  of  whales,  the  tails  of  ant-eaters,  and 
the  forearms  of  the  sloth  and  some  species  of  lemurs. 

I/ymphangiomata. — These  tumors  are  composed  of  an  abnormal 


480  INTERNATIONAL    TEXTBOOK  OF  SURGERY. 

formation  of  lymphatics.  A  lymphangioma  has  the  same  relation  to 
lymphatics  that  an  angioma  bears  to  blood-vessels. 

The  genus  contains  three  species — lymphatic  nevus ;  cavernous 
lymphangioma ;  lymphatic  cysts. 

Lymphatic  Nevus. — These  are,  as  a  rule,  colorless,  but  when  a  few 
hemic  capillaries  are  present,  they  possess  a  light  pink  tint  and  are 
slightly  raised  above  the  surrounding  skin.  When  arising  on  the  skin, 
they  rarely  exceed  2  cm.  (|-  inch)  in  diameter.  The  most  striking 
example  of  lymphangioma  occurs  in  the  mucous  membrane  of  the 
tongue,  and  may  cause  such  enlargement  of  this  organ  that  it  protrudes 
from  the  mouth.     The  condition  is  clinically  known  as  macroglossia. 

Cavernous  lymphangioma  resembles  in  structure  a  cavernous 
angioma,  except  that  the  spaces  are  filled  with  lymph  instead  of  blood. 
They  are  rare  tumors. 

Lymphatic  cysts  appear  as  congenital  cysts  in  the  neck,  axilla,  and 
adjacent  part  of  the  thoracic  wall.     Those  which  arise  in  the  posterior 


1 


'5 


4 


Fig.  198. — Lymphatic  cyst  in  the  neck  of  an  infant. 

triangle  are  sometimes  termed  "  hydrocele  of  the  neck."  Lymphatic 
cysts  are  easily  recognizable  ;  they  are  always  noticed  at  or  immediately 
after  birth,  and  are  sometimes  of  very  large  size  (Fig.  198).  The  walls 
of  such  a  cyst  are  very  thin,  and  the  tumor  is  often  translucent  like  a 
hydrocele  of  the  tunica  vaginalis  testis.  The  cysts  occur,  as  a  rule,  on 
one  side,  though  sometimes  they  are  bilateral.  Each  may  contain  a 
single  chamber  or  be  made  up  of  a  number  of  intercommunicating 
loculi  filled  with  lymph.  Some  of  them  resemble  the  large  subcu- 
taneous lymph-spaces  of  frogs. 

It  is  a  remarkable  fact  that  many  of  these  cysts  shrivel  and  disap- 
pear. They  are  exceptionally  liable  to  inflame,  and  several  cases  have 
been  recorded  in  which  they  have  been  burst  by  the  patient  falling 


CONNECTIVE-  TISSUE    TUMORS. 


481 


upon  them.  Their  proneness  to  spontaneous  cure  explains  their  rarity 
after  puberty.  The  spontaneous  effacement  of  these  cysts  is  preceded 
by  a  sudden  increase  in  their  size;  they  become  hot,  tender,  and 
inflame ;  as  these  signs  subside,  the  cyst  slowly  disappears. 

Myomata. — These  are  composed  of  unstriped  muscle-fiber.  The 
genus  contains  one  species — myoma. 

Myomata  arise  in  organs  containing  unstriped  muscle-tissue,  such 
as  the  bladder,  esophagus,  stomach,  and  intestine.  They  have  been 
found  in  the  dartoid  tissue  of  the  scrotum.  Occasionally  they  arise  in 
the  mesometrium,  Fallopian  tube,  ovary,  and  ovarian  ligament. 

The  most  important  tumor  which  is  classed  with  the  myomata  is 
that  generally  known  as  the  "  uterine  fibroid."  Fibroids  occur  in  the 
uterus  as  encapsulated  tumors ;  even  when  pedunculated  they  possess 
distinct  capsules.  The  muscle-cells  are  fusiform  in  shape  and  possess 
a  rod-like  nucleus ;  the  bundles  of  fibers  are  often  interwoven  and  pro- 
duce characteristic  whorls.  Uterine  myomata  arise  during  the  sexual 
period  of  life,  and  are  most  frequent  between  the  thirtieth  and  forty- 


\M  ).  ■*-■■■■■  :.f   lr' 


FlG.   199. — Fibroids    of  the  body  of  the  uterus.     The  capsule  of  one  has  been  opened  by 

ulceration. 


fifth  years.  They  are  rarely  single,  and  100  may  sometimes  be  counted 
in  one  uterus.  They  vary  greatly  in  the  rate  of  growth  ;  those  which 
grow  slowly  are,  as  a  rule,  very  hard,  and  contain  much  fibrous  tissue. 
Soft  myomata  grow  rapidly,  are  very  vascular,  and  sometimes  weigh 
as  much  as  30  or  even  50  pounds.  Vascular,  soft  and  rapidly  growing 
specimens  often  furnish  a  loud  systolic  murmur.  They  are  liable  to 
secondary  changes :  thus  hard  myomata  calcify,  softer  specimens 
undergo  myxomatous  degeneration,  and  large  tracts  of  tissue  assume 
the  consistency  of  honey ;  fatty  changes  are  rare,  and  lardaceous  degen- 
eration still  rarer.  When  the  tumors  are  extruded  into  the  vagina, 
they  are  liable  to  become  infected,  and  then  they  inflame  and  become 
gangrenous. 

A  myoma  of  the  uterus  may  endanger  life  by  frequent  hemorrhage, 
by  pressure  on  the  urethra  and  ureters,  inducing  renal  disturbance, 
especially  when  it  grows  from  the  cervix,  and  by  sepsis  when  an  intra- 
uterine polypus  becomes  infected  (Fig.  199)-  A  myoma  impacted  on 
the  pelvis  may  cause  fatal  intestinal  obstruction,  and  a  pedunculated 
subserous  tumor  may  entangle  a  loop  of  bowel.  When  pregnancy 
31 


482 


INTERNATIONAL    TEXT- BO  ON  OF  SURGERY. 


RADIUS 


Fig.  200. — Myeloma    of   the    lower   end   of    the 
radius  (Museum  of  St.  Thomas's  Hospital,  London). 


occurs  in  association  with  myomata,  the  complication  seriously  inter- 
feres with  the  growth  and  life  of  the  fetus,  and  often  gravely  imperils 
the  life  of  the  mother. 

A  cervix  myoma  particularly  menaces  life,  as  it  rarely  gives  rise  to 
symptoms  until  it  has  occupied  the  available  space  in  the  true  pelvis. 
It    then    compresses    the    urethra    and    leads    to    retention  of   urine. 

Large  fibroids  of  the  cervix 
are  ovoid  in  shape  and  furnish 
a  characteristic  elliptical  sec- 
tion. 

Myelomata. — These  tu- 
mors, formerly  called  myeloid 
sarcomata,  are  composed  of 
tissue  identical  with  the  red 
marrow  of  young  bone.  The 
genus  contains  a  single  spe- 
cies— myeloma.  The  cut  sur- 
face of  the  tumor  is  deep  red, 
not  unlike  a  piece  of  liver,  and 
is  very  vascular.  Microscop- 
ically, a  myeloma  abounds  in 
multinuclear  cells  embedded 
in  round  or  spindle  cells. 
The  giant  cells  are  so  numerous  as  to  constitute  the  greater  proportion 
of  the  tumor.  These  tumors  occur  most  frequently  at  the  ends  of  long 
bones ;  the  upper  end  of  the  tibia  and  the  lower  end  of  the  radius  (Fig. 
200)  are  the  common  situations.  In  the  cranial  bones  they  are  confined 
to  the  maxilla  and  mandible. 

The  patients  are  young,  rarely  above  twenty-five  years.  The  tumor 
grows  slowly,  expands  the  bone  equally,  and  thins  the  osseous  capsule, 
while  expanding  it,  until  the  bony  shell  is  so  thin  as  to  crepitate  when 
pressed  by  the  finger.  Here  and  there  the  marrow-tissue  perforates  the 
capsule,  and  markedly  pulsates  synchronously  with  the  cardiac  systole. 
Myelomata  do  not  infect  lymph-glands  and  do  not  disseminate ;  if 
the  patients  come  under  observation  before  the  tumor  has  perforated 
its  capsule,  it  may  be  thoroughly  extirpated  without  fear  of  recurrence. 
The  manner  of  effecting  "thorough  extirpation  "  varies  with  the  situa- 
tion of  the  tumor. 

Sarcomata. — These  tumors  are  composed  of  tissues  resembling 
immature  connective  tissue,  in  which  cells  preponderate  over  the  inter- 
cellular substance.  The  genus  contains  five  species,  which  are  deter- 
mined according  to  the  shape  and  disposition  of  the  cells — round-celled 
sarcoma  ;  lymphosarcoma ;  spindle-celled  sarcoma ;  alveolar  sarcoma ; 
melanosarcoma. 

Round=celled  Sarcoma — In  this  species  the  cells  are  round,  and 
there  is  very  little  intercellular  substance.  Each  cell  has  a  large,  round, 
vesicular  nucleus  and  a  small  proportion  of  protoplasm.  Blood-vessels 
are  very  abundant;  lymphatics  absent.  These  tumors  infiltrate,  dis- 
seminate, and  recur  after  removal.  Round-celled  sarcomata  are  the 
most  generalized  and  the  most  deadly  tumors  which  affect  mankind. 
They  occur  in   any  organ — bone,  brain,  muscle,  spinal    cord,    ovary, 


CONNECTIVE-TISSUE    TUMORS.  483 

testis,  and  even  in  the  delicate  tissues  of  the  eye.  They  occur  at 
any  age,  from  the  fetus  in  the  uterus  up  to  the  extreme  age-limit  of 
human  life.  There  is  abundant  reason  for  the  belief  that  many 
supposed  examples  of  round-celled  sarcoma  are  really  granulomata ; 
large  syphilitic  gummata  are  especially  liable  to  be  mistaken  for 
sarcomata. 

Lymphosarcoma. — In  this  species  the  tumor-tissue  resembles  that  of 
a  lymphatic  gland.  These  tumors  must  not  be  confounded  with  simple 
enlargement  of  a  lymph-gland,  or  the  general  increase  of  lymphadenoid 
tissue  associated  with  leukemia  or  lymphadenoma  (Hodgkin's  disease). 

Lymphosarcoma  not  only  possesses  a  definite  structure,  but  occurs 
in  definite  situations,  such  as  the  superior  mediastinum,  the  subpleural 
and  subperitoneal  tissues,  the  base  of  the  tongue,  the  larynx,  the  ton- 
sils, and  the  testes.  Like  the  small  round-celled  sarcomata,  they  are 
infiltrating  and  deadly  tumors,  but  they  have  a  more  limited  age-dis- 
tribution, occuring  most  frequently  in  young  adults. 


....■ 


FlG.  201. — Cells  from  a  spindle-celled  sarcoma  of  the  neck  of  the  uterus.     Some  of  the  cells 
present  a  cross  striation  (Pernice). 

Spindle=celled  Sarcomata. — In  this  species  the  cells,  though  they 
vary  greatly  in  size,  agree  in  the  circumstance  that  they  are  oat-shaped 
or  fusiform.  The  cells  have  a  tendency  to  run  in  bundles,  which  take 
different  directions,  so  that  in  sections  of  the  tumor  seen  under  the 
microscope  some  cells  will  be  cut  in  the  direction  of  their  length  and 
others  at  right  angles.  In  some  tumors  the  cells  are  so  thin  and 
slender  and  contain  so  little  protoplasm  that  they  seem  to  consist  only 
of  a  nucleus  and  cell-processes.  It  is  difficult  to  distinguish  such 
tissue  from  moderately  firm  fibrous  tissue.  In  other  specimens  the 
cells  are  large,  beautifully  fusiform,  and  rich  in  protoplasm  ;  some  of 
these  cells  are  transversely  striated  like  voluntary  muscle-fiber  (Fig.    20 1 ). 

Spindle-celled  sarcomata  often  contain  tracts  of  immature  hyaline 
cartilage,  fibrous  tissue,  and  spicules  of  bone.  Multinuclear  (giant) 
cells  are  usually  present.     When   particular  tissues  are  abundant  in 


484  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

spindle-celled  tumors,  they  sometimes  receive  distinguishing  names, 
such  as  chondrosarcoma,  fibrosarcoma,  myosarcoma,  etc. 

Spindle-celled  sarcomata  arise  especially  in  periosteum  and  secret- 
ing glands,  such  as  the  ovary,  testis,  parotid,  kidney,  and  the  mamma. 
"  Alveolar  Sarcoma. — This  species  differs  in  an  important  manner 
from  sarcomata  in  general,  for  the  cells  assume  an  alveolar  disposition, 
and  on  section  resemble  the  carcinomata.  There  is,  however,  this 
great  difference — they  do  not  originate  in,  or  reproduce,  the  structure 
of  secreting  glands.  This  species  illustrates  very  well  the  way  in 
which  the  structure  of  tumors  depends  on  the  tissue  in  which  they 
arise.  Alveolar  sarcomata  originate  almost  exclusively  in  the  skin,  and 
especially  in  relation  with  those  congenital  defects  known  as  hairy  and 
pigmented  moles.  The  tissue  forming  the  base  of  moles  has  the  pecu- 
liar alveolar  disposition  which  serves  as  the  histologic  type  of  this 
species  of  sarcoma. 

Melanosarcomata. — This  species  is  distinguished  by  the  presence 
of  black  pigment  (melanin)  in  the  cells  and  intracellular  substance. 
The  cells  composing  melanosarcoma  may  be  round  or  spindle-shaped ; 
in  many  they  are  collected  in  alveoli. 

The  amount  of  pigment  varies.  In  some  merely  a  brown  discolor- 
ation is  produced ;  in  others  the  tumor  is  of  a  deep  sepia  color.  It  is 
also  a  curious  fact  that  the  primary  tumor  may  contain  very  little  pig- 
ment, and  the  secondary  deposits  be  of  a  deep  black  color. 

Melanosarcomata  arise  in  the  skin  and  in  the  uveal  tract.  Cutaneous 
melanosarcomata  arise  in  connection  with  pigmented  and  hairy  moles, 
in  the  vulva,  the  anus,  and  the  nail-matrices  of  fingers  and  toes.  As  a 
rule,  they  infect  "the  nearest  lymph-glands,  disseminate  very  rapidly, 
and  recur  very  quickly  if  removed.  In  some  cases  the  tumor  seems 
to  be  mainly  a  source  of  pigment,  large  quantities  of  which  enter  the 
•circulation,  to  be  discharged  in  the  urine  as  melanin.  Intra-ocular 
melanomata  may  arise  from  any  part  of  the  uveal  tract.  They  are  ten 
times  more  common  in  the  choroid  than  in  the  ciliary  body,  and  are 
excessively  rare  in  the  iris.  Melanomata  of  the  ciliary  body  often 
exhibit  the  structure  of  carcinoma.  Intra-ocular  melanomata  have 
been  observed  as  early  as  the  fifteenth  and  as  late  as  the  eightieth  year; 
the  greater  number  occur  between  fifty  and  sixty.  Death  more  often 
results  from  the  secondary  deposits  than  from  the  local  effects  of  the 
primary  tumor. 

The  General  Characters  of  Sarcomata — All  the  species  of  this  genus 
are  very  vascular,  but  the  circulation  within  the  tumor  is  mainly  capil- 
lary ;  in  those  which  grow  rapidly  the  vessels  are  so  numerous  as  to 
produce  a  visible  pulsation  and  an  audible  "  hum."  The  force  of  the 
circulation  is  often  sufficient  to  rupture  the  capillary  channels  and  con- 
vert the  central  parts  of  the  tumor  into  a  blood-containing  cavity.  This 
intimate  relation  of  sarcomata  to  the  blood-vessels  favors  dissemina- 
tion. On  examining  the  veins  leading  from  the  tumor,  processes  from 
the  sarcoma  will  be  found  extending  into  their  lumina,  and  minute 
portions,  becoming  dislodged,  are  conveyed  to  the  right  side  of  the 
heart,  and  on  entering  the  pulmonary  circulation  they  are  arrested  in 
the  lung-tissue,  and  engraft  themselves  to  form  secondary  deposits. 
When  the  primary  tumor  occurs  in  the  vicinity  of  the  portal  circula- 


CONNECTIVE-  TISSUE    TUMORS. 


485 


tion,  the  secondary  nodules  will  be  most  abundant  in  the  liver.  Occa- 
sionally a  large  vein  like  the  renal,  iliac,  or  even  the  vena  cava  will  be 
blocked  by  sarcomatous  outrunners,  and  fragments  become  detached 
of  a  size  sufficient  to  block  the  pulmonary  artery,  or  even  the  right 
auriculoventricular  orifice.  Secondary  nodules  occur  in  other  situations 
than  the  lungs  and  liver,  for  in  some  of  the  round-celled  tumors 
nodules  amounting  to  many  hundred  may  appear  in  almost  every 
organ  of  the  body. 

The  facility  with  which  sarcomata  gain  entrance  to  veins  is  due  to 
their  extraordinary  infiltrating  properties.     In  some  instances,  and  in 


FlG.   202. — Round-celled     sar- 
coma of  the  spermatic  cord. 


FlG.  203. — Skeleton  of  a  periosteal  sarcoma  of  the  scapula 
(Museum  of  St.  Thomas's  Hospital,  London). 


the  early  stages  of  many,  sarcomata  are  encapsuled,  but  the  majority 
lack  a  capsule  and  grow  in  every  direction.  Thus,  a  sarcoma  of  a 
bone  will  send  outrunners  along  the  Haversian  canals ;  in  the  skull, 
portions  will  creep  into  the  foramina  and  recesses ;  a  sarcoma  of  a 
voluntary  muscle  will  invade  its  constituent  bundles  and  even  separate 
its  ultimate  fasciculi.  Yet  this  infiltrating  tendency  is  easily  restrained 
in  the  early  stages.     For  instance,  a  sarcoma  of  muscle  is  easily  retained 


486 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


within  the  sheath,  and  a  sarcoma  of  the  spermatic  cord  will  quickly 
occupy  the  cord  and  become  moulded  by  its  outer  tunics  (Fig.  202). 
This  is  also  true  of  subperiosteal  sarcomata. 

Sarcomata  are  devoid  of  lymphatics ;  hence  the  adjacent  lymph- 
glands  are  not,  as  a  rule,  in- 
fected. Should  the  sarcoma 
implicate  the  overlying  skin 
or  mucous  membrane  and 
ulcerate,  then  the  lymph- 
glands  will  enlarge. 

Sarcomata  are  very  liable 
to  degenerative  changes.  It 
has  already  been  mentioned 
that  extravasations  of  blood 
will  produce  spurious  cysts, 
and  a  like  effect  follows  necro- 
sis of  considerable  proportions 
of  the  tumor.  Myxomatous 
change  will  often  cause  lique- 
faction and  form  a  cavity  in  a 
large  tumor,  big  enough  to 
accommodate  the  fist.  Calci- 
fication and  ossification  are 
frequent  changes  in  sarcomata 
growing  from  periosteum,  and 
produce  abundant  arborescent 
processes  and  spicules  (Fig. 
203).  When  the  sarcoma 
arises  in  the  central  parts  of 
a  long  bone  and  grows  slowly, 
it  will  expand  the  surrounding 
osseous  tissue  (Fig.  204). 

In  slow-growing  sarcomata 
of  the    spindle-celled    species 
tracts  of  hyaline  cartilage  are 
often  found.     Such  are  some- 
times called  cliondrosarcomata. 
Distribution. —  Sarcomata 
arise   from   connective   tissue, 
and  although  this  tissue  occurs 
in  every  part  of  the  body,  they 
are    far    commoner    in    some 
situations  than  in  others.  Thus 
they  are  frequent  in  subcutane- 
ous tissue,  fascia,  intermuscu- 
lar septa,  and  the  periosteum. 
They    are    rare    as    primary 
tumors       of       muscle-tissue, 
striped  or  unstriped.       Even  when  hollow  muscles,  like  the  bladder, 
intestine,  and  uterus,  are  the  seat  of  sarcomata,  they  originate  in  the 
mucous  membrane ;  and,  most  striking  of  all,  a  sarcoma  of  the  heart 


FlG.  204. — Shaft  of  a  tibia  expanded  by  a  central 
tumor  (Museum  of  the  Royal  College  of  Surgeons, 
London). 


CONNECTIVE-  TISSUE    TUMORS. 


487 


is  unknown.  Even  the  delicate  connective  tissue  of  the  retina,  the 
uveal  tract,  the  neuroglia  of  the  brain  and  spinal  cord,  and  the  sheaths 
of  the  nerves  are  attacked  by  these  deadly  tumors. 

In  considering  the  distribution  of  sarcomata,  it  is  necessary  to  make 
special  mention  of  their  occurrence  in  secreting  glands.  All  compound 
glands,  such  as  the  kidney,  testis,  parotid,  prostate,  mamma,  etc.,  con- 
tain a  fair  amount  of  connective  tissue,  and  it  would  naturally  come 
about  that  a  sarcoma  arising  in  this  tissue  would  tend  to  entangle  the 
gland-acini  in  its  substance.  Thus,  in  the  kidney  uriniferous  tubules 
would  be  expected.  Follicles  occur  in  an  ovarian  sarcoma,  and 
galactophorous  ducts  and  glands  in  a  mammary  sarcoma.  These  are 
often  termed  adenosarcomata,  a  term  apt  to  mislead. 

A  very  striking  fact  in  connection  with  sarcomata  arising  in  secret- 
ing glands  is  the  frequent  occurrence  of  hyaline  cartilage,  and  in  some 
— e.  g.,  the  kidney  and  testis — striped  muscle-fiber.  When  striped 
spindle-cells  are  present,  the  tumor  is  sometimes  called  a  myosarcoma. 


Fig.  205. 


-Sarcoma  of  the  kidney  of  an  infant,  arising  from  the  connective  tissue  in  the 
renal  sinus. 


It  is  a  fact  of  considerable  interest  that  sarcomata  are  especially 
rare  in  the  liver,  the  thyroid,  pancreas,  and  lungs ;  and,  as  showing 
that  their  structure  is  modified  by  the  nature  of  the  connective  tissue 
in  which  they  arise,  reference  need  only  be  made  to  those  originating 
in  the  retina,  to  alveolar  sarcoma  of  pigmented  moles,  and  sarcoma 
(deciduoma)  arising  in  a  gravid  or  recently  gravid  uterus.  Age 
modifies  the  liability  to,  as  well  as  the  structure  of,  sarcomata  in  some 
glands.  Thus,  retinal  sarcomata  are  common  in  infants,  bilateral  in 
nearly  half  the  cases,  and  are  unknown  after  twelve  years  of  age. 
Intra-ocular  melanomata  are  unknown  before  puberty,  and  are  uni- 
lateral. Sarcomata  of  the  ovaries  are  more  common  before  puberty 
than  in  later  life,  and  are  often  bilateral ;  in  adults  they  are  usually 
unilateral. 

Adrenal  Tumors  [Suprarenal  Capsule). — The  species  of  this  genus 
are  very  remarkable  tumors,  and  until  our  knowledge  of  them  is  more 


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extensive  and  precise,  it  will  be  judicious  to  let  them  rank  among  the 
sarcomata. 

Tumors  arising  in  and  reproducing  the  peculiar  structure  of  the 
adrenal  have  been  many  times  recorded.  Tumor-like  bilateral  enlarge- 
ment of  the  adrenals  has  been  observed  in  children,  whereas  in  adults 
the  enlargement  affects  one  adrenal,  and  may  attain  the  dimensions  of 
a  melon.  In  some  instances  there  have  been  secondary  deposits  in  the 
viscera,  especially  the  liver.  Sarcoma  of  the  adrenal,  though  rare, 
occurs  in  children,  and  may  attack  both  adrenals.  A  remarkable  feat- 
ure sometimes  associated  with  such  tumors  is  a  general  overgrowth  of 

hair,  occasionally  accompanied 
with  an  alteration  in  the  color 
of  the  skin,  which  assumes  a 
"  coppery  hue."  It  is  a  re- 
markable fact  that  tumors  some- 
times of  large  size  and  histo- 
logically identical  with  the  zona 
fasciculata  arise  in  accessory 
adrenals.  These  bodies  are 
fairly  frequent ;  they  occur  in 
the  capsule  of  the  liver  and  be- 
tween the  layers  of  its  falciform 
ligament ;  also  beneath  the  cap- 
sule of  the  kidney  (Fig.  205), 
and  in  the  course  of  the  sper- 
matic artery.  Less  frequently 
they  have  been  detected  in  the 
anterior  layer  of  the  meso- 
metrium  of  the  fetus  at  term 
and  in  early  infancy. 

Tumors  supposed  to  arise  in 
accessory  adrenals  situated  in 
the  kidney  are  very  important. 
They  occur  as  encapsulated 
masses  in  the  cortex,  and  rarely 
communicate  with  the  renal  pelvis  ;  hence,  hematuria  is  not  so  con- 
stant as  in  sarcomata  springing  from  the  connective  tissue  in  the  sinus 
of  the  kidney.  A  striking  feature  of  these  tumors  is  their  delicate 
structure  and  the  frequency  with  which  blood-extravasations  take 
place  in  them,  whereby  the  central  parts  are  often  transformed  into 
cyst-like  spaces  filled  with  blood-coagulum  (Fig.  206).  This  liability 
to  hemorrhage  is  also  a  common  feature  of  these  tumors  when  aris- 
ing in  the  adrenal  itself.  The  majority  of  the  specimens  on  record 
were  observed  in  men  and  women  between  the  fortieth  and  fifty-fifth 
years  of  life.  Tumors  of  the  adrenals  and  tumors  that  arise  in  acces- 
sory adrenals  simulate  each  other  during  life  so  closely  that  it  is  as  yet 
impossible  to  differentiate  them  by  clinical  methods  or  to  distinguish 
them  from  other  species  of  renal  tumors. 


Fig.  206. — Adrenal  tumor  of  the  kidney. 
This  tumor  in  structure  resembled  the  adrenal 
at  the  third  month  of  intra-uterine  life. 


EPITHELIAL    TUMORS.  489 

H.  EPITHELIAL  TUMORS. 

In  this  group  of  tumors  the  presence  of  epithelium  and  its  mode 
of  distribution  are  the  essential  and  distinguishing  features.  In  the 
bodies  of  animals  epithelium  is  disposed  in  various  ways  and  serves 
various  functions.  In  many  situations  where  it  is  protective  it  is 
arranged  in  layers  (stratified) ;  in  others  it  is  modified  to  form  hair, 
feather,  bristles,  nail,  or  horn  ;  in  others  it  dips  into  the  underlying 
tissues  to  form  secreting  organs  (glands),  some  of  which  are  very 
simple,  as  in  the  intestine,  or  exceedingly  complex,  as  in  the  liver, 
kidney,  or  testis.  Whether  a  gland  is  simple  or  complex,  the  principle 
of  construction  is  identical — namely,  narrow  channels  lined  with  epi- 
thelium resting  upon  a  connective-tissue  base,  in  which  blood-vessels, 
lymphatics,  and  nerves  ramify.  The  recesses  of  glands  communicate, 
either  directly  or  by  means  of  a  duct,  with  a  free  surface.  To  this  rule 
there  are  three  exceptions — the  thyroid  gland,  the  pituitary  body,  and 
the  ovary. 

The  variations  in  the  disposition  of  epithelium  enable  epithelial 
tumors  to  be  arranged  in  three  genera :  Papilloma ;  adenoma  ;  carci- 
noma. 

Papilloma  ( Warts). — A  wart  consists  of  an  axis  of  fibrous  tissue 
containing  blood-vessels,  surmounted  by  epithelium.  It  may  be  simple, 
or  covered  with  secondary  processes  and  resemble  a  mulberry. 

This  genus  contains  four  species  :  1.  Warts  ;  2.  Villous  papillomata; 
3.  Intracystic  warts ;    4.  Psammomata. 

Warts. — These  occur  in  the  skin,  singly  or  in  multitudes.  They 
are  rarely  painful,  unless  irritated.  In  adults  they  are  common  on  the 
glans  penis  and  prepuce,  and  on  the  vulva  and  surrounding  skin,  as  the 
result  of  irritating  urethral,  preputial,  and  vaginal  discharges.  Warts 
arise  on  the  laryngeal  mucous  membrane,  especially  of  children.  Large 
solitary  warts  often  contain  pigment,  and  later  in  life  are  liable  to  be 
the  starting  point  of  a  melanoma.  The  thick  layers  of  epithelium  on 
large  warts  sometimes  decompose  (ulcerate)  and  become  horribly 
offensive.  Occasionally  the  surface-cells  become  keratinized  and  form 
horn.  Epithelioma  sometimes  arises  at  the  base  of  a  large  solitary 
wart,  especially  if  the  wart  has  been  irritated. 

The  crops  of  warts  which  occur  on  the  hands  of  children  never 
lead  to  serious  consequences,  and,  as  a  rule,  disappear  spontaneously, 
sometimes  as  if  by  magic. 

Villous  Papillomata. — This  species  consists  of  feather-like  tufts 
resembling  chorionic  villi.  Each  villus  consists  of  a  delicate  axis  of 
connective  tissue,  containing  delicate  loops  of  blood-vessels  and  sur- 
mounted by  epithelium.  The  villi  may  be  simple  or  compound.  Thus, 
in  structure  they  resemble  chorionic  villi. 

The  villous  papilloma  grows  from  the  mucous  membrane  of  the 
bladder,  and  occasionally  from  the  pelvis  of  the  kidney.  Cases  are 
known  in  which  villous  papillomata  of  the  renal  pelvis  have  been  asso- 
ciated with  villous  tufts  in  the  bladder,  around  the  orifices  of  the  ureters, 
probably  due  to  the  grafting  of  epithelium  derived  from  the  villi  in  the 
kidney  or  the  vesical  mucous  membrane.  An  interesting  variety  of 
villous  papilloma  arises  from  the  choroid  plexuses  of  the  cerebral  ven- 


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tricles ;  when  large  and  situated  in  the  fourth  ventricle,  they  have  pro- 
duced death  from  pressure.  Villous  papillomata  of  the  choroid  plex- 
uses rarely  attain  a  large  size  without  undergoing  calcification  (see 
Psammomd).  Renal  and  vesical  villous  papillomata  give  rise  to  oft- 
recurring  bleeding,  and  sometimes  cause  death. 

Intracystic  Papillomata — Warts  may  arise  from  any  epithelial 
surface,  and  as  all  true  cysts  are  lined  with  epithelium,  they  are  liable 
to  warts.  Intracystic  warts  occur  in  the  following  situations — in  cysts 
of  the  mammary  glands  ;  cysts  of  the  paroophoron,  parovarium,  and 
Gartner's   duct;  and  cysts  arising  in  accessory  thyroid  glands. 

It  should  be  remembered  that  many  intracystic  growths  are  struct- 
urally adenomata,  and  in  the  case  of  mammary  cysts  it  is  difficult 
to  decide  the  nature  of  the  intracystic  process  without  the  aid  of  the 
microscope. 

The  example  represented  in  Fig.  207  shows  a  cyst  formed  by  the 
dilatation  of  a  galactophorous  sinus,  and  in  this  instance  the  knob-like 
process  is  composed  of  villi.  In  such  a  case  it  is  easy  to  trace  the 
duct  belonging  to  the  sinus  into  the  cyst,  and  it  is  often  possible  during 

life  to  squeeze  fluid  from  the 
cyst  and  make  it  appear  at  the 
nipple.  In  some  cases  the 
patients  are  much  inconveni- 
enced by  the  involuntary  es- 
cape of  blood-stained  fluid  from 
the  nipple,  often  in  quantity 
sufficient  to  soak  their  linen. 
Psammomata. — These  tu- 
mors are  composed  of  globular 
bodies  consisting  of  epithelium 
arranged  in  layers,  usually  cal- 
cified and  embedded  in  connec- 
tive tissue.  The  amount  of 
calcareous  matter  they  contain 
is  very  variable ;  sometimes 
they  are  of  stony  hardness. 
Psammomata  occur  exclusively 
in  connection  with  the  pia  mater 
of  the  brain  and  spinal  cord. 
They  are  particularly  liable  to 
grow  from  the  choroid  plexuses 
of  the  ventricles.  A  very  fav- 
orite situation  is  the  tufts  of 
villi  which  protrude  from  the 
lateral  recesses  of  the  fourth 
ventricle.  Psammomata  aris- 
ing from  the  choroid  plexuses  of  the  lateral  and  the  fourth  ventricle 
are  often  bilateral.  In  the  latter  situation  they  exert  injurious  pressure 
on  the  facial,  trigeminal,  and  auditory  nerves. 

A  psammoma  arising  in  connection  with  the  spinal  membranes  leads 
to  far  more  serious  results  than  a  tumor  of  the  same  size  arising  in  the 
lateral  ventricles.     It  is  a  curious  fact  that  there  is  singular  uniformity 


Fig.    207. — Warts  in  a  cyst  formed  by 
galactophorous  sinus. 


dilated 


EPITHELIAL    TUMORS.  49 1 

in  the  size  and  shape  of  psammomata  observed  in  the  spinal  canal. 
They  lead  to  slow,  progressive  paralysis  and  death. 

Horns. — There  are  four  varieties  of  these  curious  structures — seba- 
ceous horns  ;  wart  horns  ;  cicatrix  horns  ;  nail  horns. 

Sebaceous  horns  may  arise  in  any  situation  where  sebaceous  glands 
exist.  They  are  formed  from  the  epithelium  of  the  gland,  and  some- 
times attain  a  length  of  many  centimeters.  The  horns  are  tough  and 
present  a  longitudinal  fibrillation  ;  when  soaked  in  a  weak  solution  of 
liquor  potassae,  the  tissue  softens  and  falls  away  in  flakes. 

Wart  horns  are  identical  in  appearance  with  sebaceous  horns,  and 
the  only  means  of  deciding  between  them  is  to  split  the  horns  longi- 
tudinally and  ascertain  whether  the  base  is  occupied  by  a  wart  or  a 
sebaceous  cyst. 

Sebaceous  horns  are  common  on  the  scalp,  and  wart  horns  are  most 
frequent  on  the  glans  penis  near  the  corona. 

Cicatrix  horns  are  rare ;  they  occur  chiefly  in  the  scar  left  by  burns. 
Horns  of  this  kind  are  usually  laminated  like  pie-crust. 

Nail  horns  are  simply  the  greatly  elongated  and  thickened  nails 
found  especially  on  the  big  toes  of  bed-ridden  and  dirty  patients.  These 
nails  sometimes  attain  the  length  of  7  cm.  (2.73  in.),  and  resemble 
miniature  ram's  horns. 

Adenomata. — An  adenoma  is  a  tumor  constructed  on  the  type  of, 
and  growing  in  connection  with,  a  secreting  gland.  The  species  of  this 
genus  are  determined  by  the  glands  in  which  they  arise.  The  chief 
species  of  adenomata  are — mammary,  sebaceous,  thyroid,  pituitary, 
prostatic,  parotid,  hepatic,  renal,  ovarian,  gastric,  intestinal,  and  uterine. 
In  some  glands,  such  as  the  liver,  parotid,  mamma,  and  thyroid,  they 
occur  as  encapsuled  tumors.  In  the  intestine,  especially  the  rectum, 
and  in  the  cervical  canal  of  the  uterus  they  appear  as  pedunculated 
bodies  (polypi).  Often  the  acini  of  an  adenoma  become  distended  with 
perverted  secretion  and  form  large  fluid-containing  spaces.  Such  some- 
times receive  special  names ;  thus,  in  the  mamma  it  would  be  called  a 
cystic  adenoma  or  an  adenocele ;  in  the  thyroid  gland,  a  bronchocele ; 
in  the  ovary,  a  multilocular  ovarian  cyst. 

In  size,  adenomata  exhibit  great  variations ;  some  rarely  exceed  the 
dimension  of  a  pea,  others  may  attain  the  size  of  a  foot -ball.  In  number 
they  vary  greatly ;  one  only  may  exist,  or  many  may  be  present. 

The  liability  of  secreting  glands  to  become  the  seat  of  adenomata  is 
very  variable  ;  thus,  they  are  excessively  common  in  the  mamma,  ovary, 
and  thyroid  ;  rare  in  the  liver,  kidney,  and  pituitary  body  ;  and,  though 
common  in  the  prostate  and  parotid  glands,  are  almost  unknown  in  the 
submaxillary,  sublingual,  lacrimal,  and  pancreatic  glands. 

The  following  statements  hold  good  for  all  the  species  :  When  com- 
pletely removed,  there  is  no  recurrence  ;  they  do  not  infect  the  neigh- 
boring tissues  or  lymph-glands,  nor  give  rise  to  secondary  deposits. 
When  an  adenoma  causes  death,  it  is  in  consequence  of  mechanical 
complications  due  to  its  environment.  Thus  a  small  tumor  of  the 
pituitary  body  will  cause  death  from  pressure  on  the  brain ;  a  broncho- 
cele may  injuriously  narrow  the  trachea;  an  intestinal  polypus  occa- 
sionally induces  intussusception ;  and  a  small  prostatic  adenoma  will 


492 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


sometimes  jut  into  the  vesical  orifice  of  the  urethra  and  cause  death  by 
renal  complications. 

As  a  rule,  adenomata  are  tumors  of  adolescence  and  adult  life. 
Hepatic  and  prostatic  adenomata  occur  commonly  after  the  mid-period 
of  life.  Cystic  adenomata  are  liable  to  secondary  changes  of  some 
importance ;  thus,  the  fluid  contained  in  cysts  which  have  existed  sev- 
eral years  in  the  mamma,  thyroid,  or  ovary  often  contains  large  quanti- 
ties of  cholesterin.  Hemorrhage  not  infrequently  takes  place  in  large 
cysts  of  these  glands,  and  Reverdin  once  found  a  large  number  of  mul- 
berry-like bodies,  composed  of  coagulated  fibrin,  in  a  large  bronchocele 
in  an  old  man.  The  walls  of  very  old  bronchoceles  are  liable  to  be 
completely  calcified  ;  and  calcareous  patches  are  sometimes  found  in  old 
cysts  of  the  ovary  and  mamma.  A  much  more  important  change  is 
the  formation  of  villi  (papillomata)  and  buds  of  glandular  tissue  on  the 
inner  walls  of  cystic  adenomata.  They  are  common  in  the  breast  and 
ovary,  and  have  been  observed  in  the  thvroid. 


FIG.  208. — Adenoma  of  the  endometrium. 

Carcinotnata  (Cancer). — A  carcinoma  is  a  malignant  tumor  aris- 
ing in  epithelium.  When  the  source  of  a  cancer  is  the  epithelium  of  a 
secreting  gland  it  is  called  glandular  cancer,  but  when  it  arises  from 
a  surface  covered  with  stratified  epithelium,  like  the  skin  or  lips,  it  is 
called  squamous-celled  cancer. 

The  microscopic  structure  of  a  cancer  is  very  simple  and  consists  of 
columns  of  cells,  so  that  when  the  columns  are  cut  at  right  angles 
the  section  has  the  appearance  of  a  number  of  alveolar  spaces  filled 
with  epithelium.  The  walls  of  the  alveoli  consist  of  fibrous  tissue  in 
which  blood-  and  lymph-vessels  ramify.  The  cell  columns  branch  in 
various  directions,  and  thus  produce  in  some  sections  very  complicated 
patterns.  The  cells  composing  the  columns  depend  upon  the  character 
of  the  epithelium  in  which  the  cancer  arises,  and  this  feature  is  so  strik- 
ing that  the  histologist  can  often  pronounce  with  certainty  the  particu- 
lar gland  in  which  a  cancer  arose  merely  from  studying  a  carefully 
prepared  section  with  a  microscope. 


EPITHELIAL    TUMORS. 


493 


Carcinomata  infiltrate  surrounding  tissues,  and  extend  beyond  the 
gland  in  which  they  originate ;  they  are  very  prone  to  involve  surface- 
tissues,  to  ulcerate,  and  quickly  to  infiltrate  lymph-glands  in  the  neigh- 
borhood. A  marked  feature  of  carcinomata  is  their  tendency  to 
undergo  degenerative  changes  and  necrosis. 

The  relationship  between  secreting  glands,  adenoma,  and  carcinoma 
may  be  studied  in  the  uterus.  The  glands  in  the  endometrium  are 
tubular  and  lined  with  columnar  epithelium. 

Adenomata  arising  in  the  endometrium  preserve  the  tubular  type  of 
glands  (Fig.  208),  whereas  carcinoma  originating  in  the  same  situation 
consists  of  masses  of  these  tubules,  greatly  enlarged  and  stuffed  with 
epithelium  (Fig.  209). 

Cancers  are  exceptionally  liable  to  become  disseminated  and  give 
rise  to  knots  or  nodules  known  as  secondary  deposits,  which  may 
make  their  appearance  in  any  organ  or  tissue  of  the  body,  even  the 
bones.  These  cancerous  deposits  are  due  to  minute  portions  of  the 
primary  tumor  being  transported  by  the  lymph-  and  blood-vessels  as 


Fig.  209. — Carcinoma  of  the  endometrium. 


minute  emboli,  which,  when  lodged  in  suitable  situations,  engraft  them- 
selves and  form  nodules  which  in  histologic  characters  reproduce  the 
parent  tumor.  The  amount  of  dissemination  varies  widely.  In  some 
cases  the  secondary  knots  may  be  limited  to  the  liver,  whilst  in  another 
and  apparently  identical  case,  in  so  far  as  structure  is  concerned,  they 
occur  in  scores,  deposited  in  almost  every  organ  of  the  body,  even  in 
the  bones. 

Although  every  secreting  gland  is  liable  to  become  the  seat  of 
cancer,  yet  some  are  much  more  prone  to  it  than  others.  The  com- 
monest situations  are  the  female  mammae  and  the  glands  of  the 
cervical  canal  of  the  uterus.  Cancer  of  the  glands  at  the  pyloric  orifice 
of  the  stomach  and  in  the  colon  and  rectum  is  common  in  both  sexes, 
but  it  is  somewhat  uncommon  in  the  prostate  and  thyroid  glands.    Dis- 


494  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

eased  organs  are  more  liable  to  become  cancerous  than  those  which 
are  healthy. 

In  some  situations  the  relative  frequency  of  carcinoma  and  sarcoma 
has  not  been  determined,  the  two  conditions  being  comprised  under 
the  term  malignant  disease.  Thus,  malignant  tumors  of  the  antrum 
are  generally  classed  as  sarcomata ;  but  many  of  the  most  deadly 
tumors  which  occupy  this  cavity  are  carcinomata  arising  in  the  race- 
mose glands  lodged  in  its  mucous  membrane. 

Carcinoma  in  the  restricted  sense  now  enforced  by  pathologists  is 
unknown  before  puberty ;  it  is  rare  before  twenty-five ;  the  liability 
increases  with  each  decade  of  life.  These  facts  are  the  reverse  of  those 
observed  in  adenomata. 

The  modes  by  which  cancer  kills  varies  with  its  situation  and  the 
nature  of  the  organ  implicated.  Thus,  cancer  of  the  pyloric  glands 
blockades  the  orifice  and  causes  death  by  starvation  ;  mammary  cancer 
invades  the  pleura  and  gives  rise  to  secondary  deposits  in  lungs, 
liver,  brain,  etc. ;  uterine  cancer  is  apt  to  be  fatal  from  bleeding,  from 
uremia  due  to  the  vesical  extremities  of  the  ureters  and  the  bladder 
being  involved  mechanically  in  the  growth,  or  from  the  renal  channels 
becoming  infected  by  septic  micro-organisms  which  flourish  in  the  dis- 
charges and  necrotic  tissue  of  the  cancer ;  carcinoma  of  the  colon  will 
cause  death  from  intestinal  obstruction,  septic  peritonitis,  or  actual  per- 
foration ;  carcinoma  of  the  thyroid  gland  will  lead  to  fatal  dyspnea ; 
and  cancer  of  the  antrum  causes  death  by  pneumonia  due  to  the  direct 
inhalation  of  septic  material. 

Squamous-celled  Cancer. — This  species  always  arises  in  the 
stratified  epithelium  of  skin  or  mucous  membrane,  and  is  characterized 
by  cone-shaped  ingrowths  of  epithelium  which  invade  the  subjacent  tis- 
sue. It  may  arise  on  any  surface  covered  with  stratified  epithelium,  but 
is  more  common  in  regions  where  there  is  a  transition  from  one  kind 
of  epithelium  to  another,  and  especially  where  skin  and  mucous  mem- 
brane come  in  relation  to  each  other — e.g.,  the  anus,  the  vulva,  and 
the  lip.  Other  common  situations  are  the  tongue,  the  gums,  and  the 
mucous  membrane  of  the  cheek.  It  sometimes  occurs  at  the  edges  of 
cicatrices  and  chronic  ulcers.  Many  examples  have  been  reported  in 
which  it  has  attacked  the  base  of  an  old  wart  or  a  wart  horn. 

Squamous-celled  cancer  may  make  its  appearance  as  a  wart-like 
growth,  more  frequently  a  small  circular  ulcer  with  raised  rampart-like 
edges  or  as  a  fissure :  it  is  particularly  apt  to  arise  on  the  scrotum  of 
chimney-sweeps. 

Although  these  three  clinical  varieties  look  so  different,  they  are 
identical  in  structure.  When  sections  are  cut  so  as  to  include  the  mar- 
gin of  the  ulcer  and  underlying  tissue,  the  surface-epithelium  will  be 
seen  invading  it  in  the  form  of  long,  simple  or  ramified  columns.  Weich- 
selbaum  has  pointed  out  that  the  cells  composing  the  columns  retain 
more  or  less  the  characters  of  the  epithelium  from  which  they  originate. 
When  the  cones  grow  rapidly,  the  cells  become  flattened,  and  some 
finally  cornify  (Fig.  210).  In  this  way  the  so-called  epithelial  pearls  or 
nests  are  produced.  When  lateral  pressure  is  made  on  a  fresh  speci- 
men, whitish  plugs  are  forced  out ;  these  plugs  are  the  cellular  cones. 

The    primary   ulcers,   when    left    to    themselves,   may  extend   and 


EPITHELIAL    TUMORS. 


495 


involve  extensive  tracts  of  tissue,  or  fungate  and  form  large  granula- 
ting, cauliflower-like  masses.  In  both  conditions  the  superficial  parts 
are  continually  cast  off  in  a  foul,  fetid  discharge  containing  sloughs, 
cellular  detritus,  pus,  and  blood.  Vascular  tissues  are  quickly  infil- 
trated and  destroyed ;  even  bone  is  rapidly  eroded.  Not  the  least 
remarkable  feature  of  this  disease  is  the  rapidity  with  which  it  infects 
the  adjacent  lymph-glands.  The  large  size  which  the  glands  attain  in 
some  instances  is  out  of  all  proportion  to  the  dimensions  of  the  initial 
lesion,  for  a  cancer  focus  I  cm.  (0.4  inch)  in  diameter  will  lead  to  the 
formation  of  a  mass  of  enlarged  lymph-glands  as  big  as  a  cocoanut. 
The  gland-complication  is  always  a  serious 
element  of  danger,  for  in  some  situations  the 
enlarged  glands  may  compress  vital  struct- 
ures, such  as  the  trachea  or  esophagus ;  or, 
when  they  disintegrate  and  ulcerate,  large 
blood-vessels  may  be  opened,  and  fatal  bleed- 
ing ensue.     Dissemination  is  unusual. 

In  whatever  situation  it  arises,  squamous- 
celled  cancer  usually  destroys  life  quickly 
from  exhaustion,  bleeding,  pain,  or  the  impli- 
cation of  such  structures  as  the  pleura, 
trachea,  esophagus,  urethra,  and  bladder,  or 
even  the  dura  mater,  according  to  the  situa- 
tion of  the  initial  lesion.  Septic  pneumonia 
is  a  common  mode  of  death  when  the  mouth, 
nasal  passages,  fauces,  larynx,  or  gullet  are 
implicated  in  the  ulceration.  Even  when 
freely  removed,  the  disease  is  very  apt  to  recur  locally,  or  far  more 
frequently  in  the  lymph-glands. 

Adenomata  and  Carcinomata  of  Sebaceous  Glands. — 
Although  the  preceding  account  of  adenomata  and  carcinomata  holds 
good  for  glands  in  general,  it  is  necessary  to  consider  separately  the 
diseases  of  sebaceous  glands. 

Sebaceous  Cysts. — In  its  best-known  form  a  sebaceous  gland 
appears  as  an  appendage  to  a  hair-follicle,  the  secretion  of  the  gland 
being  discharged  into  the  follicle.  In  some  situations,  especially  in  the 
skin  of  the  nose  and  cheek,  the  hair  is  so  delicate  and  the  glands  are 
so  large  that  the  hair  seems  to  be  an  appendage  of  the  gland ;  in  other 
situations — e.  g.,  the  corona  of  the  penis,  and  the  labium  minus — the 
glands  are  very  large,  but  hair  is  absent.  In  every  situation  where 
these  glands  exist  (even  in  ovarian  dermoids),  the  walls  of  the  acinus  are 
apt  to  become  thickened  and  the  gland-secretion  (sebum)  retained,  giving 
rise  to  a  definite  rounded  swelling  known  as  a  sebaceous  cyst.  Such 
a  cyst  forms  a  rounded  circumscribed  swelling  lodged  in  the  skin  ;  and 
in  all  situations,  save  the  scalp,  close  scrutiny  will  reveal  a  small  circu- 
lar black  dot  or  dimple,  indicating  the  orifice  of  the  duct.  Sometimes 
the  orifice  is  open,  and  slight  pressure  causes  sebum  to  exude.  These 
cysts  may  be  as  small  as  coriander  seed,  and  they  rarely  exceed  the 
dimensions  of  a  tangerine  orange.  Many  may  grow  concurrently  in 
the  same  individual,  especially  in  the  scalp. 

Sebaceous  cysts  have  a  capsule  of  fibrous  tissue  lined  with  stratified 


FlG.  210. • — Arrangement  of 
the  cells  in  the  cones  of  squa- 
mous-celled  cancer. 


496 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


epithelium.  They  contain  a  pultaccous  matter  consisting  of  shed 
epithelium,  fat,  and  cholesterin  ;  sometimes  the  cyst-contents  consist 
of  pure  sebum  resembling  Chinese  white.  An  arachnid,  the  demodex 
folliculorum,  is  often  present.  The  capsule  of  a  sebaceous  cyst,  espe- 
cially in  the  scalp,  is  thick  and  laminated  like  an  onion. 

These  cysts  are  liable  to  secondary  changes;  thus,  the  cyst-wall 
may  inflame  and  suppurate,  the  cyst-contents  sometimes  decompose, 
and  occasionally  calcification  occurs.  An  inflamed  cyst  may  burst, 
and  its  wall  become  converted  into  a  large  fungating  mass,  particu- 
larly on  the  scalp  (Fig.  211);  this  condition  is  apt  to  be  mistaken  for 
epithelioma,  especially  when  the  associated  lymph-glands  are  en- 
larged. These  cysts  are  not  infrequently  the  source  of  one  variety 
of  cutaneous  horn. 

Sebaceous  Adenomata. — It  has  been  so  customary  to  regard  all 
tumors  arising  in  sebaceous  glands  as  simple  cysts  that  it  is  quite  an 
exceptional  event  for  them  to  be  submitted  to  microscopic  examination. 
However,  this  mode  of  investigation  serves  to  show  that  some  of  them 
are  solid  and  resemble  the  exuberant  masses  which  form  upon  the  nose, 
and  which  are  often  referred  to  as  "  nasal  lipomata."  They  are  due  to 
overgrowth  of  the  large  sebaceous  glands  so  abundant  in  the  skin  of 

the  nose.  A  careful  micro- 
scopic examination  of  sup- 
posed "fungating  wens"  will 
show  that  man)-  of  them  are 
ulcerating  sebacous  adenomata. 
Sebaceous  Carcinoma  {Ro- 
dent Ulcer). — In  British  writ- 
ings on  Surgery  it  has  been 
customary  for  many  years  to 
describe  under  the  name  of  ro- 
dent ulcer  a  form  of  cancer 
which  exhibits  extraordinary 
clinical  characters.  In  its  com- 
mon form  a  smooth,  rounded 
knob  of  about  the  size  of  a 
split  pea  is  noticed  on  the  skin 
of  the  face,  either  on  the  nose, 
eyelids,  orbital  angles,  or  cheek. 
This  knob  may  remain  for  years 
(seven,  eight,  or  twelve)  and 
cause  no  inconvenience  save 
unsightliness ;  then  without 
obvious  reason  it  may  ulcerate 
and  destroy  the  surrounding 
skin  and  underlying  tissues,  involving  all  tissues  in  its  vicinity — skin, 
muscles,  fat,  cartilage,  eyeball,  and  bone — and  producing  horrible 
destruction  of  the  face,  in  some  cases  even  destroying  the  base  of  the 
skull  and  meninges  and  exposing  the  brain.  To  produce  such  terrible 
effects  the  disease  requires  sometimes  five,  ten,  or  even  more  years. 
In  its  course  it  destroys  everything,  never  cicatrizes,  and  is  painless. 
In  recent  years  the  histology  of  the  early  knobs  which  mark  the 


Fig.  211. — Ulcerating  sebaceous  adenoma 
(fungating  wen). 


DERMOIDS.  497 

beginning  of  the  disease  has  been  investigated  with  great  care.  All 
observers  agree  that  the  disease  begins  as  a  solid  growth  beneath  the 
epidermis.  If  in  this  stage  the  nodule  is  excised  and  sections  are 
examined  microscopically,  the  nodule  will  be  seen  to  consist  of  gland- 
ducts  filled  with  epithelium,  though  sometimes  they  take  the  form 
of  solid  cylinders.  In  the  latter  stages,  when  ulceration  is  in  full  sway, 
these  appearances  are  lost. 

The  origin  of  the  initial  knob  has  been  ascribed  to  the  following 
sources:  I.  Sebaceous  glands;  2.  Sweat-glands;  3.  The  hair-follicle; 
4.  The  outer  layer  of  the  root-sheath  of  a  hair;  5.  Epithelial  remnant 
in  the  course  of  the  facial  fissures ;  6.  Vestiges  of  the  tear-pits  of 
ruminants. 

My  own  investigations  induce  me  to  ascribe  its  origin  to  the  seba- 
ceous glands. 

Although  rodent  cancer  arises  mainly  in  the  facial  situations  already 
mentioned,  it  may  occur  on  the  neck,  and  has  been  met  with  on  the 
trunk,  but  never,  so  far  as  I  know,  on  the  limbs.  It  occurs  most  fre- 
quently in  advanced  life,  but  is  not  uncommon  between  thirty  and 
fifty.  It  has  been  recorded  at  the  age  of  twenty,  but  never  before 
puberty  (fifteen  years).  It  is  more  frequent  in  men  than  in  women. 
The  extraordinary  features  which  distinguish  it  from  the  common  species 
of  carcinomata  are  the  following:  1.  It  does  not  infect  lymph-glands; 
2.  It  does  not  disseminate  ;  3.  Though,  as  a  rule,  solitary,  it  may  be, 
and  often  is,  multiple ;  4.  Its  duration  may  extend  over  many  years. 

Happily,  of  all  species  of  carcinomata,  this  gives  the  best  results  to 
adequate  operative  treatment.  When  freely  excised  in  the  early  stages, 
recurrence  is  very  exceptional.  Even  in  the  very  late  stages,  as 
Moore  demonstrated  in  1867,  bold  and  free  excision  usually  gives 
excellent  results,  so  far  as  the  course  of  the  disease  is  concerned. 

m.  DERMOIDS. 

These  are  tumors  furnished  with  skin  or  mucous  membrane,  occur- 
ring in  situations  where  these  structures  are  not  found  under  normal 
conditions.  Dermoids  only  possess  tissues  which  naturally  belong  to 
skin  or  mucous  membrane. 

The  group  contains  four  genera:  I.  Sequestration  dermoids;  2. 
Tubulodermoids  ;   3.  Ovarian  dermoids ;  4.  Dermoid  patches  (moles). 

Sequestration  Dermoids. — :The  species  of  this  genus  arise  in 
detached  or  sequestered  portions  of  the  surface  epithelium,  mainly  in 
situations  where,  during  embryonic  life,  coalescence  takes  place  between 
skin-covered  surfaces.  They  are  met  with  in  the  mid-line  of  the  trunk, 
from  the  occipital  protuberance  along  the  spine  to  the  coccyx,  through 
the  perineum  (including  the  scrotum  and  penis),  and  onward  through 
the  mid-line  of  the  abdominal  and  thoracic  wall  to  the  neck.  In  the 
face  and  neck  they  arise  in  the  lines  of  the  facial  and  branchial  fissures. 
In  the  pinna,  dermoids  arise  in  the  lines  of  fusion  of  the  tubercles  out 
of  which  the  pinna  is  formed. 

The  characters  and  the  modes  by  which  dermoids  arise  may  be 
illustrated  in  the  nose.  In  the  early  embryo  the  central  part  of  the 
face  is  represented  by  an  opening  from  which  five  fissures  radiate  (Fig. 

32 


498 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


212).     The  upper  pair  are  the  orbitonasal,  the  two  lower  are  the  max- 
illary fissures,  and  a  fifth  the  intermandibular.     The  median  fold  pro- 


Frotitonasal  process. 
Globular  process. 

Maxillary  process. 
Mandibular  process. 


Orbital  fissure. 

1  liter  nasal  fissure. 
Maxillary  fissure. 
Intermandibular  fissure. 


Fig.  212. — Head  of  an  embryo,  showing  the  disposition  of  the  facial  fissures 
(semi-diagrammatic). 

jecting  into  the  opening  from  above  is  the  frontonasal  process,  which 
ultimately  forms  the  nose.  Each  angle  of  the  frontonasal  plate  is 
rounded  and  is  known  as  the  globular  process ;  they  unite  to  form  the 

alae  of  the  nose,  the  premaxillae, 
and  the  central  median  piece  (the 
philtrum)  of  the  upper  lip.  The 
elongation  of  the  frontonasal  proc- 
ess lengthens  the  orbitonasal  fis- 
sures. The  sides  of  the  frontonasal 
plate  coalesce  superficially  with  the 
maxillary  processes,  the  lines  of 
fusion  being  permanently  indicated 
in  the  adult  by  the  nasofacial  sul- 
cus, and  on  the  deep  surface  by 
the  lacrimal  duct.  This  brief  ac- 
count of  the  development  of  the 
face  indicates  that  the  nose  is  re- 
lated with  three  fissures :  the  orbito- 
nasal on  each  side ;  the  internasal, 
in  the  mid-line  of  the  nose,  marks 
the  line  of  union  of  the  globular  processes.  In  each  of  these  situations 
faults  of  three  kinds  occur:  1.  The  fissure  persists;  2.  It  may  close 
imperfectly  and  leave  a  fistula ;  3.  A  portion  of  surface  epithelium 
becomes  sequestered  and  forms  a  dermoid. 

In  the  case  of  the  nose  itself,  the  internasal  fissure  is  very  apt  to 
be  imperfectly  obliterated  and  leave  a  fissure,  and  from  its  skin-lined 
recesses  hairs  may  sprout. 

Dermoids  at  the  root  of  the  nose  arise  in  a  different  manner.  In 
the  early  embryonic  stages  the  frontonasal  process  consists  of  hyaline 
cartilage  covered  with  skin.  Gradually  the  nasal  bones  develop  between 
the  skin  and  cartilage,  eventually  causing  the  underlying  cartilage  to 
disappear.  In  the  process  of  separating  skin  from  cartilage,  fragments 
of  surface  epithelium  become  sequestered  and  give  rise  to  dermoids. 


Fig.  213. — The  nose,  to  show  the  lines  of 
coalescence. 


DERMOIDS. 


499 


Dermoids  of  the  scalp  arise  in  this  way,  and  occasionally  project  on 
the  deep  surface  of  the  cranium,  and  cause  death  by  interfering  with 
the  brain. 

Sequestration  dermoids  rarely  attain  a  large  size ;  the  majority  do 
not  exceed  5  centimeters  (2  inches)  in  diameter.  Structurally  they 
appear  as  cysts  lined  with  skin  which  resembles  the  cutaneous  invest- 
ment of  the  parts  in  which  they  arise.  Thus,  a  dermoid  of  the  eyelid 
will  have  its  skin-lining  like  that  of  the  eyelid ;  in  the  scalp,  the  hairs 
and  glands  are  like  those  of  the  normal  scalp,  and  so  on.  Sequestration 
dermoids  very  rarely  contain  teeth.  Dermoids  in  the  nasofacial  sulcus 
are  rare,  whilst  they  are  of  frequent  occurrence  in  the  neighborhood  of 
the  orbit,  but  are  more  common  at  the  temporal  than  at  the  nasal  angle. 

Implantation  Cysts. — It  has  long  been  recognized  that  dermoids  do 
not  occur  in  the  limbs ;  yet,  occasionally,  small  skin-lined  cysts  are  met 
with  in  the  skin  of  the  hand  and  fingers.  It  has  been  demonstrated 
that  these  cysts  are  the  results  of  injury,  such  as  pricks  and  cuts, 
whereby  fragments  of  the  skin  are  carried  into  the  subcutaneous  tissue 
and  subsequently  give  rise  to  skin-lined  cysts.  These  are  called 
implantation  cysts,  from  the  manner  of  their  origin.  They  may  attain 
the  size  of  a  bantam's  egg,  and  occur  not  only  in  the  limbs,  but  on  the 
trunk,  scalp,  and  face.  Very  many  examples  have  been  recorded  in  the 
cornea  and  iris  as  the  result  of  punctured  wounds  of  the  globe,  as  well 
as  the  consequence  of  operations,  such  as  iridectomy  and  cataract- 
extraction.  The  cysts  are  considered  here,  since  they  serve  as  experi- 
mental proof  that  sequestered  portions  of  skin  may  act  as  tumor-germs. 

Tllbulodermoids. — In  the  human  embryo  there  are  certain  canals 
and  passages  which  normally  disappear  before  birth.  These  are  known 
as  obsolete  canals.  Three  of 
these,  the  thyroglossal  duct,  the 
branchial  clefts,  and  the  postanal 
gut,  are  occasionally  the  source 
of  dermoids. 

Lingual  Dermoids. — The  va- 
riety which  arises  in  the  center  of 
the  tongue,  between  the  geniohyo- 
glossi  muscles,  has  its  origin  in  the 
persistent  glossal  segment  of  the 
thyroglossal  duct  (Fig.  214). 

Rectal  Dermoids. — There  are 
three  situations  in  relation  with  the 
rectum  in  which  dermoids  arise : 
1.  They  may  hang  as  polypi  from 
the  mucous  membrane  ;  2.  They 
sometimes  lie  between  the  rectum 
and  coccyx,  extending  upward  into 
the  hollow  of  the  sacrum ;  or,  3. 
They  project  from  between  the 
rectum  and  coccyx  as  huge  congenital  tumors  (familiar  as  congenital 
sacrococcygeal  tumors).  The  last  two  species  arise  in  persistent  seg- 
ments of  the  postanal  gut.  The  solid  skin-covered  tumors  lying  be- 
tween the  coccyx  and  rectum  are  probably  teratomata. 


Thyroid 
p-land. 


Trachea. 


Fig.  214. — The  thyroglossal  duct  (Marshall). 


500 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


Branchial  Dermoids. — These  arise  in  persistent  branchial  fissures. 
They  are  congenital,  and  lie,  as  a  rule,  beneath  the  deep  cervical  fascia. 

Tubulodermoids,  apart  from  their  mode  of  origin,  differ  from  the 
sequestration  genus  in  the  following  points  :  They  often  attain  very  large 
proportions,  exhibit  a  more  complex  structure,  and  not  infrequently 
contain  teeth. 

Ovarian  Dermoids. — This  genus  differs  from  other  dermoids  in 
their  mode  of  origin  as  well  as  in  the  great  variety  of  structure  they 
contain.  The  ovarian  dermoid  arises  in  that  region  of  the  ovary  con- 
taining the  follicles  (the  oophoron),  and  the  glandular  and  epithelial 
elements  are  derived  from  the  rich  follicular  epithelium. 

An  ovarian  dermoid  may  contain  hair  (Fig.  215)  which  is  some- 
times a  meter  (39.37  inches)  in  length  ;  skin-glands  of  every  variety — 
sebaceous,  sudoriparous,  and  mammary — also  horn,  nail,  and  epithelial 


FlG.  215. — An  ovarian  dermoid. 


pearls ;  and  collections  of  shed  epithelium  which  sometimes  assume  the 
form  of  pills,  and  may  number  3000  or  4000  in  one  cyst.  Bone  is  not 
uncommon,  and  teeth  (Fig.  216)  may  be  numerous  (1  to  300). 

Ovarian  dermoids  sometimes  attain  prodigious  proportions  (50  lbs.). 
There  is  no  reliable  evidence  of  the  existence  of  an  ovarian  dermoid 
in  a  child  under  one  year  of  age.  In  this  respect  they  differ  from 
sequestration  dermoids,  which  are  nearly  always  congenital. 

Moles. — This  term  is  applied  to  a  congenital,  pigmented,  and 
usually  hairy  patch  upon  the  skin.  Moles  vary  greatly  in  size.  Some 
are  like  dots,  others  may  be  as  big  as  the  palm,  and  occasionally  a 


DERMOIDS. 


50I 


mole  may  involve  half  the  face  or  trunk.  They  commonly  occur 
where  hair  is  scanty,  and  are  conspicuous  objects.  Moles  sometimes 
arise  on  the  scalp  and  conjunctiva.  The  hair  on  moles  is  usually  short, 
but  it  may  be  10  centimeters  (3.9  inches)  or  more  long.  It  is  furnished 
with  sebaceous  glands ;  sweat-glands  are  often  present,  even  in  the  con- 
junctival variety.  The  most  important  histologic  feature  in  moles,  both 
hairy  and  hairless,  is  the  fact  that  the  tissue  immediately  underlying 
them  has  a  disposition  like  that  characteristic  of  an  alveolar  sarcoma. 

A  mole  bleeds  freely  when  its  surface  is  abraded ;  it  is  liable  to 
ulcerate ;  and,  later  in  life,  is  prone  to  become  the  starting  point  of  a 
melanoma.  A  large  pigmented  mole  often  overlies  a  plexiform  neu- 
roma.   (See  page  479.) 

Teratomata. — A  teratoma  is  an  irregular  conglomerate  mass,  con- 
taining the  tissues  and  fragments  of  the  viscera  of  a  suppressed  fetus, 
attached  to  an  otherwise  normal  individual.  Strictly,  the  consideration 
of  teratomata  belongs  to  teratology,  but  certain  species  are  very  apt  to 
be  confounded  with  dermoids. 


Fig.  216. — Ovarian  teeth. 


When  a  single  ovum  gives  origin  to  two  embryos,  they  may  remain 
separate  or  be  conjoined.  Occasionally,  when  the  embryos  remain  dis- 
tinct and  have  a  common  placenta,  one  embryo  goes  on  to  full  develop- 
ment, but  the  other  becomes  an  "  ill-formed  lump,"  sometimes  furnished 
with  arms  and  legs,  but  often  having  the  limbs  blended  with  the  trunk. 
These  are  known  as  acardiac  fetuses.  When  the  twins  are  conjoined, 
both  may  go  on  to  full  development,  or  one  may  become  suppressed 
and  remain  as  an  imperfectly  developed  fetus  attached  to  one  that  is 
fully  formed.  The  bearer  of  a  parasitic  fetus  of  this  kind  is  termed  the 
autosite.  The  degree  to  which  the  parasitic  fetus  is  developed  varies 
very  greatly.  When  the  limbs  are  developed,  there  is  no  difficulty  in 
recognizing  it ;  but  when  it  is  a  sessile  mass,  there  is  more  difficulty. 

An  acardiac  fetus  differs  from  a  parasitic  fetus  merely  in  the  fact  that 
the  former  is  connected  with  its  twin  by  means  of  the  placenta,  whilst 
the  latter  is  directly  attached  to  its  companion.  Parasite  fetuses  may  be 
attached  to  any  part  of  the  head  or  trunk  of  the  autosite.  The  poste- 
rior sacral  region  is  perhaps  the  commonest.  In  a  few  rare  cases  the 
suppressed  fetus  has  been  found  on  the  posterior  wall  of  the  belly  or 
the  thorax. 

The  essential  difference  between  a  teratoma  and  a  dermoid  is  this : 


5<D2  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

A  teratoma  contains  formed  organs,  such  as  intestine,  liver,  kidney,  etc., 
and  complete  bones,  such  as  a  vertebra,  perhaps  with  a  piece  of  spinal 
cord  or  a  completely  formed  limb ;  dermoids,  on  the  other  hand,  con- 
tain skin  or  mucous  membrane  (sometimes  both)  and  such  structures — 
glands,  hair,  nails,  teeth,  etc. — as  are  normally  derived  from  skin  and 
mucous  membrane. 

rv.  CYSTS. 

Cysts  (or  cystomata)  result  from  the  abnormal  dilatation  of  pre- 
existing tubules  or  cavities.  In  the  simplest  forms  they  consist  of  a 
wall,  usually  composed  of  fibrous  tissue,  but  not  infrequently  mixed 
with  plain  muscle-fiber.  The  cyst-contents  may  be  mucus,  bile,  saliva, 
etc.,  according  to  the  nature  of  the  organ  with  which  the  cyst  is  con- 
nected. 

Cysts  may  be  arranged  in  four  genera:  I.  Retention  cysts;  2. 
Tubulocysts ;   3.   Hydroceles  ;  4.  Gland-cysts. 

Retention  Cysts. — When  the  duct  of  a  gland  is  obstructed,  the 
secretion,  hindered  from  escaping,  accumulates  in  the  ducts  and  acini, 
and  dilates  them.  If  the  obstruction  be  maintained  or  oft-repeated,  the 
gland-tissue  atrophies,  and  finally  the  gland  and  its  duct  are  converted 
into  a  fluid-containing  sac  or  cyst.  Typical  retention  cysts  arise  in  con- 
nection with  hollow  organs  the  inner  walls  of  which  are  provided  with 
glands,  such  as  the  uterus,  gall-bladder,  and  vermiform  appendix. 

Retention  cysts  may,  and  often  do,  reach  very  large  proportions, 
endangering  life  by  interfering  with  the  functions  of  the  organ  in  which 
they  arise,  or  by  mechanically  disturbing  adjacent  viscera.  Frequently, 
pathogenic  micro-organisms  gain  access  to  the  contents  of  cysts,  and 
establish   suppuration  with  all  its  attendant  evils. 

Tubulocysts. — This  genus  includes  cysts  arising  in  functionless 
ducts — c.  g.,  the  urachus,  vitello-intestinal  duct,  parovarian  tubules,  and 
Gartner's  duct.  Functionless  ducts  must  not  be  confounded  with 
obsolete  canals.     (See  page  499.) 

Hydroceles. — These  cysts  are  due  to  excessive  accumulation  of 
fluid  in  a  diverticulum  or  pouch  of  the  peritoneum.  The  following  are 
the  chief  species  :  hydrocele  of  the  tunica  vaginalis  testis  ;  hydrocele 
of  the  canal  of  Nuck  ;  hydrocele  of  hernial  sacs  ;  hydrocele  of  the 
ovarian  pouch  (probably  confined  to  a  few  mammals) ;  omental  hydro- 
celes, or  cysts  due  to  accumulation  of  fluid  between  the  layers  of  the 
great  omentum. 

Gland-cysts. — In  many  compound  glands  the  secretion  escapes 
by  a  common  duct.  Thus,  in  the  salivary  glands — c.  g.,  the  parotid — 
the  excretory  conduit  is  known  as  Steno's  duct ;  the  duct  of  the  kidney 
is  the  ureter,  and  that  of  the  submaxillary  gland  is  known  as  Wharton's 
duct.  In  other  compound  glands  the  secretions  open  into  a  number 
of  channels,  each  with  a  discrete  orifice.  For  example,  the  mammary 
or  milk-ducts  open  separately  on  the  apex  of  the  nipple ;  the  lacrimal 
and  sublingual  glands  have  many  ducts  with  separate  terminations.  In 
compound  glands  of  this  kind  a  distinction  must  be  made  between 
cysts  arising  in  the  ducts  or  in  connection  with  the  acini  of  the  glands. 
For  instance,  in  the  kidney,  obstruction  to  the  main  duct  (ureter)  leads 
to  hydronephrosis,  but  when  the  uriniferous  or  gland-tubes  form  cysts, 


CYSTS. 


503 


then  the  organ  becomes  a  conglomerate  cystic  body  (Fig.  217).  This 
is  well  seen  in  the  mamma,  where  a  cyst  arising  in  the  milk-duct  is 
situated  near  the  base  of  the  nipple  (Fig.  218):  by  pressure  the  fluid 
maybe  made  to  exude  through  the  duct;  but  when  the  glandular  acini 
become  cystic,  the  organ  is  dotted  throughout  with  fluid-containing 
cavities. 

A  cyst  due  to  distention  of  Wharton's  duct  is  called  a  ranala  ;  one 
arising  in  the  ducts  of  the  lacrimal  gland  is  termed  dacryops. 

Adrenal. 


Urachus. 


Bladder.  - 


ift    ,'\v:        \  •-''If'' 


Urethra 


Ureter 


/;:ih/c 


Fig.  217. — Urinary  organs  of  a  fetus  with  imperforate  urethra.  On  one  side  the  ureter  is 
dilated  into  a  large  cyst,  and  the  renal  pelvis  is  sacculated  (hydronephrotic) ;  the  opposite 
ureter  is  narrow,  and  the  uriniferous  tubules  are  ectatic. 

Pseudocysts. — There  are  many  conditions  often  classed  as  cysts 
which  may  with  greater  propriety  be  arranged  as  a  sub-group  contain- 
ing four  genera:  I.  Diverticula;  2.  Bursas;  3.  Neural  cysts ;  4.  Para- 
sitic cysts. 

Diverticula. — The  term  diverticulum  denotes  a  hernia  or  protrusion 
of  the  lining  membrane  of  a  cavity  through  a  defective  spot  in  its  walls. 
Diverticula  occur  in  mucous  canals — e.  g.,  the  pharynx,  esophagus, 
larynx,  trachea,  intestine,  and  bladder.  A  hernial  protrusion  of  the 
synovial  membrane  of  a  joint  is  called  a  synovial  cyst,  and  in  the  case 
of  tendon-sheaths,  a  ganglion.  Localized  protrusions  of  the  meninges 
of  the  brain  and  spinal  cord  are  known  as  meningoceles. 

Bursae. — Where  muscles  or  their  tendons  glide  over  osseous  promi- 


504 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


nences,  and  in  situations  where  the  skin  is  exposed  to  intermittent 
pressure  combined  with  friction,  membranous  sacs  tilled  witn  glairy 
fluid  occur.  These  are  known  as  bursae,  and  are  often  a  source  of 
inconvenience,  especially  when  they  inflame.  Common  examples  are 
the  prepatellar  and  olecranon  bursae.  Very  large  examples  are  some- 
times found  over  the  tuberosity  of  the  ischium  and  the  great  trochanter. 


FIG.  218.— Cyst  due  to  dilatation  of  a  milk-duct.     It  had  existed  for  many  years,  and  contained 

much  cholesterin. 

Troublesome  bursae  are  found  under  many  corns  and  associated  with 
bunions. 

Neural  Cysts. — This  genus  includes  the  abnormal  conditions  of 
brain  known  as  encephalocele  and  dilatation  of  the  cerebral  ventricles 
(hydrocephalus).  It  also  includes  malformations  of  the  spinal  cord 
included  in  the  term  spina  bifida. 

Parasitic  Cysts. — This  includes  echinococcus  cysts  and  colonies 
and  the  cysticercal  stage  of  the  tenia. 


CHAPTER    XVI. 
FRACTURES. 

GENERAL  CONSIDERATIONS. 

Fracture,  in  the  general  surgical  sense,  is  the  breaking  of  hard 
animal  tissue ;  in  the  special  surgical  sense  employed  here,  the  term  is 
applied  to  the  breaking  of  bone.  It  should  be  borne  in  mind  that  a 
fracture  is  a  wound — a  wound  of  bone — and  that  in  its  etiology,  symp- 
toms, pathology,  and  treatment  it  is  amenable  to  the  same  laws  which 
govern  wounds  in  other  tissues. 

Varieties. — The  varieties  of  fracture,  for  convenience  of  classifica- 
tion, may  be  divided  as  follows  : 

A.  According  to  the  Lines  of  Fracture. — The  terms  transverse, 
oblique,  dentate,  spiral,  V-shaped,  T-shaped,  and  longitudinal  fracture 
are  self-explanatory.  A  stellate  fracture  is  one  in  which  multiple  lines 
of  fracture  radiate  from  a  central  point.  By  comminuted  fracture  is 
understood  a  breaking  of  bone  into  small  fragments  :  this  is  usually 
caused  by  direct,  crushing  injuries.  When  a  bone  is  broken  in  several 
places,  more  widely  separated  than  in  comminuted  fracture,  the  term 
multiple  fracture  is  applied.  A  splintered  fracture  is  one  in  which  a 
small,  superficial  fragment  of  bone  is  chipped  off.  This  sometimes 
occurs  as  the  result  of  muscular  action,  whereby  a  fragment  of  bone  to 
which  the  muscle  is  attached  is  torn  away.  The  term  is  also  applied 
to  multiple  parallel  lines  of  fracture,  close  together,  and  terminating  in 
the  free  surface  or  broken  end  of  a  bone.  Punctured  or  penetrating 
fracture  is  usually  a  variety  of  comminuted  fracture,  caused  by  a  pene- 
trating instrument  or  projectile.  It  may,  however,  be  caused  by  a  sharp 
instrument  which  produces  only  a  separation  of  the  bone,  by  parting 
its  substance  to  either  side  as  it  enters.  By  gunshot  fracture  is  under- 
stood the  fracture  produced  by  a  projectile  from  a  firearm.  Such 
fractures  vary  from  an  ordinary  penetrating  fracture  to  the  most 
severe  comminuted  fracture.  They  are  of  especial  importance  because 
they  are  always  associated  with  a  lacerated,  usually  infected  wound  of 
the  soft  parts.  A  fracture  with  loss  of  substance  is  one  in  which,  at 
the  time  of  injury,  a  portion  of  the  bone  is  separated  or  entirely 
removed  from  its  normal  connections. 

B.  According  to  the  Degree  of  Fracture. — A  complete  fracture  is 
one  in  which  the  bone  is  divided  into  two  or  more  parts  by  a  line  or 
lines  of  fracture  involving  its  whole  thickness.  When  the  bone  is  not 
completely  separated  into  two  or  more  parts — as  in  the  case  of  the 
shaft  of  a  long  bone  with  a  crack  passing  only  partly  across  its  longi- 
tudinal axis,  and  in  the  case  of  a  flat  bone,  when  the  fracture-line 
does  not  extend  completely  from  one  side  of  the  bone  to  the  other — 
the  term  incomplete  fracture  is  used.     To  this  second  class  belongs  the 

505 


506  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

green-stick  or  bending  fracture — that  is,  a  fracture  caused  by  the  bend- 
ing of  a  long  bone  to  such  a  degree  that  the  bone-tissue  separates  on 
the  side  which  suffers  traction,  and  does  not  separate  upon  the  opposite 
side,  or  side  of  compression.  Fissured  fracture,  or  fissure,  is  a  form  of  the 
incomplete  variety  in  which  a  single  line  or  lines  of  fracture  traverse 
only  a  part  of  the  thickness,  breadth,  or  length  of  a  bone.  It  is  most 
commonly  observed  in  the  skull,  and  sometimes  as  a  longitudinal 
fracture  of  the  long  bones.  In  the  long  bones  it  may  be  produced 
transversely  or  obliquely  by  the  same  force  that  causes  green-stick 
fracture  in  a  less  brittle  bone.  Depressed  fracture  is  usually  incomplete  ; 
though  there  is  a  form  of  complete  depressed  fracture  in  which  an 
area  involving  the  whole  thickness  of  the  bone  is  completely  separated 
and  driven  in.  The  incomplete  depressed  fracture  consists  in  the  bend- 
ing or  pressing  in  of  an  area,  without  a  circumferential  separation 
involving  the  whole  thickness  of  the  bone.  The  crushing  in  of  the 
bony  wall  of  an  antrum  or  sinus  or  of  the  vitreous  layer  of  a  bone 
into  the  underlying  cancellous  structure  constitutes  an  incomplete 
depressed  fracture. 

C.  According  to  the  Displacement  of  the  Fragments. — Depressed 
fracture  of  the  complete  variety  is  observed  especially  in  the  skull,  and 
is  of  importance  because  of  the  accompanying  injury  to  the  underlying 
viscera.  Fracture  with  transverse  displacement  is  one  occurring — as  is 
the  case  with  the  five  following  varieties — in  long  bones,  and  is  charac- 
terized by  a  displacement  of  one  or  both  fragments  in  a  direction  trans- 
verse to  the  long  axis  of  the  bone.  When  the  degree  of  displacement 
is  greater  than  the  diameter  of  the  bone,  the  contraction  of  the  overly- 
ing muscles  tends  naturally  to  the  production  of  fracture  with  overriding. 
Fracture  with  rotary  displacement  is  the  result  of  the  destruction  of  the 
normal  relations  by  a  rotation  of  one  or  both  fragments  upon  the  long 
axis.  Fracture  with  angular  displacement  not  only  occurs  in  complete 
fractures,  but  is  usually  the  only  displacement  in  incomplete  or  green- 
stick  fractures  of  the  long  bones.  It  is  very  variable  in  its  degree, 
and  may  be  associated  with  lateral  dislocation  to  such  an  extent  that  a 
T-shaped  displacement  results.  When  displacement  occurs  in  the 
direction  of  the  long  axis  of  the  bone,  the  lesion  is  designated  as  frac- 
ture with  longitudinal  displacement,  though  the  term  is  understood  to 
apply  only  to  fractures  with  longitudinal  separation  or  drawing  apart 
of  the  fragments.  An  impacted  fracture  is  the  driving  of  one  fragment 
into  another,  or  the  telescoping  of  the  bone. 

D.  According  to  the  Location  of  the  Fracture. — The  separation  of 
an  epiphysis  is  an  accident  peculiar  to  young  persons.  It  is  of  impor- 
tance because,  in  the  healing,  the  cartilage  which  separates  the  epiphysis 
from  the  diaphysis  often  becomes  prematurely  ossified,  and  thus  the 
subsequent  longitudinal  growth  of  the  bone  is  interfered  with.  Fracture 
of  the  shaft  is  the  most  frequent  of  fractures.  Fracture  of  the  head  of 
a  bone,  because  of  its  almost  invariable  involvement  of  the  articular 
surface,  assumes  a  special  importance.  Fracture  of  the  neck  of  a  bone 
may  or  may  not  involve  that  part  of  the  neck  which  lies  within  the 
joint.  The  term  "  fracture  of  the  extremity  of  a  bone  "  is  included  in  the 
above-mentioned  classes.  Intracapsular  or  intra-articular  fracture  is  a 
fracture  lying  wholly  within  the  joint.     Extra-articular  fracture  is  one 


FRACTURES.  507 

lying  in  close  relation  to  the  joint,  but  still  external  to  the  joint- 
capsule.  When  the  line  of  fracture  involves  the  bone  both  within  and 
without  the  joint,  it  is  designated  as  mixed  fracture.  Intercondyloid 
fracture  is  a  fracture  which  enters  a  joint  between  the  condyles.  The 
separation  of  an  apophysis  is  similar  to  the  separation  of  a  splinter  by 
direct  external  violence  or  muscular  action.  By  multiple  fracture  is 
understood  the  simultaneous  breaking  of  two  or  more  bones. 

E.  According  to  the  Presence  or  Absence  of  other  Injuries. — A 
simple  or  closed  fracture  is  one  that  is  not  complicated  by  a  wound 
extending  from  the  seat  of  fracture  through  the  overlying  skin  or 
mucous  membrane.  A  compound  or  open  fracture  is  one  that  is  asso- 
ciated with  such  a  wound.  This  variety  of  fracture  is  of  the  greatest 
importance,  because  it  adds  to  the  bone-injury  the  possibility  of  all 
the  dangers  and  complications  of  an  open  wound.  The  dangers  inher- 
ent in  a  compound  fracture  are  greater  than  those  in  a  simple  fracture, 
complicated  by  a  wound  of  the  soft  parts  of  the  same  extent,  not  con- 
nected with  the  break  in  the  bone.  The  combination  with  a  fracture 
of  an  open  wound  involving  the  soft  tissues  adds  an  extra  hazard 
which  is  entirely  out  of  proportion  to  the  combined  dangers  of  the 
two  conditions  when  existing  separately.  A  complicated  fracture  is  one 
associated  with  a  wound  of  a  large  nerve,  vessel,  joint,  or  internal 
organ,  or  with  the  dislocation  of  a  joint  with  which  a  broken  bone 
articulates. 

F.  According  to  the  Etiology  of  the  Fracture. — Under  this  head- 
ing are  two  great  classes — traumatic  fractures  and  pathological fractures. 
The  first  occur  as  the  immediate  result  of  violence  to  healthy  bone,  or 
to  bone  which  is  strong  enough  to  withstand  a  considerable  degree  of 
breaking  force.  The  second  occur  in  bones  which  have  become  so 
fragile,  as  the  result  of  pre-existing  local  disease,  that  a  slight  degree 
of  force  suffices  to  cause  a  fracture. 

The  traumatic  fractures  are  the  following :  Fracture  by  direct  force 
implies  that  the  fracture  occurs  at  the  location  where  the  primary  force 
strikes  the  bone.  Fracture  by  indirect  force  implies  that  the  fracturing 
force  is  applied  at  a  point  remote  from  the  place  where  the  bone  breaks, 
and  is  transmitted  through  the  bone.  It  is  customary  to  speak  also  of 
fracture  by  twisting  and  fracture  by  traction.  Fracture  by  contre-coup, 
or  opposite-stroke,  is  a  term  applied  to  that  form  of  indirect  fracture 
of  the  skull  in  which  the  fracture  occurs  on  the  opposite  side  from 
that  at  which  the  force  is  applied.  These  are  fractures  by  external 
violence.  In  fracture  by  muscular  contraction  the  violence  is  done  by 
force  generated  within.  Spontaneous  fracture  is  an  old  term  applied  to 
fracture  of  the  pathological  variety. 

(For  the  varieties  of  pathological  fracture,  see  the  Predisposing 
Causes  of  Fracture.) 

Etiology. — Under  this  head  are  considered  the  predisposing  and 
exciting  causes  of  fracture.  Predisposing  causes  which  induce 
abnormal  fragility  of  bone  are  caries  and  necrosis  ;  tumors  of  bone, 
either  primary  or  metastatic ;  pressure  or  encroachment  upon  the  bone 
by  extra-osseous  tumors ;  osteomyelitis ;  osteoporosis ;  fragilitas 
ossium  ;  osteitis  deformans  ;  echinococcus  ;  actinomycosis  ;  syphilis  ; 
tuberculosis ;  atrophy  as  a  result  of  disuse  or  circulatory  defects ;  fatty 


508  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

degeneration;  mercurial  poisoning;  rheumatism  and  gout.  Aside  from 
these  more  particularly  local  causes  are  certain  general  disturbances 
which  render  bone  more  liable  to  fracture.  These  are  rickets  ;  osteo- 
malacia;  scrofula;  insanity;  locomotor  ataxia;  general  paralysis,  and 
other  diseases  involving  the  trophic  centers ;  old  age  and  general 
inanition.     In  some  families  there  is  an  hereditary  liability  to  fracture. 

There  are  certain  other  predisposing  causes  of  fracture  which  do 
not  depend  upon  pathological  changes.  Persons  of  the  male  sex, 
because  of  greater  exposure  to  violence,  sustain  more  fractures  than 
the  female.  In  certain  occupations  the  liability  to  fracture  is  greater 
than  in  others.  The  occurrence  of  fracture  is  influenced  by  the  season. 
It  is  not  true  that  bone  is  more  brittle  in  cold  weather,  but,  because  of 
the  more  tonic  state  of  the  muscular  system  in  cold  weather,  the  joints 
are  held  more  rigidly,  and  thus  injury  is  more. apt  to  cause  fracture. 
The  presence  of  ice  in  certain  seasons  adds  to  the  danger.  The  shape 
and  the  situation  of  certain  bones  are  factors  in  their  predisposition  to 
fracture. 

The  exciting  causes  of  fracture  are  external  violence  and  muscular 
action.  By  external  violence  is  meant  the  violent  or  forcible  contact 
of  a  part  of  the  body  with  some  external  body  or  force.  Such  a  force 
may  be  the  cause  of  fracture  by  direct  action — that  is,  the  fracture  may 
occur  directly  at  the  place  where  the  external  force  is  applied ;  as,  for 
example,  when  the  leg  is  struck,  and  breaks  at  the  place  of  contusion. 
Or  the  force  may  act  indirectly,  and  cause  a  fracture  at  some  point 
remote  from  the  place  where  the  external  force  meets  the  body ;  as, 
for  example,  the  breaking  of  the  radius  by  a  fall  upon  the  hand. 
Muscular  action  is  not  an  uncommon  cause  of  fracture.  The  violence 
is  done  by  the  sudden  and  strong  contraction  of  muscle,  acting  usually 
upon  some  bony  prominence  or  bone  which  projects  as  a  lever  over  its 
underlying  fulcrum.  The  most  common  seats  of  fractures  caused  in 
this  way  are  the  olecranon  process  of  the  ulna,  which  is  broken  by  the 
triceps  muscle,  and  the  patella,  which  is  broken  by  the  quadriceps 
extensor  muscle. 

Symptoms. — The  immediate  symptoms  of  fracture  are  local  and 
general. 

Local  Immediate  Symptoms. — Abnormal  mobility  is  a  symptom 
which  depends  upon  the  possibility  of  displacement  of  the  fragments. 
When  the  bones  of  a  limb  are  broken,  it  may  be  possible  to  move  the 
limb  in  directions  in  which  the  normal  limb  could  not  be  moved,  and 
the  size  of  the  arc  through  which  the  limb  normally  moved  may  be 
increased. 

False  Point  of  Motion. — The  above  symptoms  depend  upon  the 
presence  of  an  abnormal  point  of  motion  in  the  bone.  The  fragments 
may  remain  in  exact  apposition,  or  displacement  may  be  present. 

Crepitus. — This  is  the  peculiar  grating  feeling  that  is  imparted  to 
the  examining  hand  when  broken-bone  surfaces  are  rubbed  together. 
Sometimes  it  can  be  detected  by  the  sense  of  hearing.  It  is  also  man- 
ifested to  the  patient  by  the  sense  of  feeling. 

These  are  the  most  important  symptoms  of  fracture.  They  apply 
more  particularly  to  the  fractures  of  the  long  bones,  and  belong  espe- 
cially to   the   class   of   complete  fractures.     Crepitus    may  be    absent 


FRACTURES.  509 

because  of  the  incompleteness  of  the  fracture,  or  because  of  the  pres- 
ence of  blood-clot  or  other  soft  tissue  between  the  fragments,  or 
because  of  an  overriding  or  impaction  of  the  same.  In  the  case  of  the 
fracture  of  a  bone  which  has  a  parallel  companion,  the  latter  acts  as  a 
splint,  and  these  symptoms  may  be  elicited  with  difficulty.  This  dif- 
ficulty is  increased  in  the  cases  with  very  thick  limbs,  and  also  in 
V-shaped  and  firmly  interdigitating  fractures. 

Deformity. — The  degree  of  deformity  about  a  fracture  depends 
largely  upon  the  degree  of  displacement  of  the  fragments.  Aside 
from  the  immediate  deformity  as  a  result  of  such  displacement,  there 
must  needs  be  about  a  fracture  more  or  less  injury  to  the  soft  tissues, 
the  degree  of  which  depends  much  upon  the  degree  of  the  displace- 
ment. This  tearing  of  the  soft  tissues  causes  a  swelling,  due  to  the 
extravasation  of  serum  and  the  escape  of  blood  from  the  torn  vessels. 
However  much  this  may  amount  to,  there  is  always  bleeding 
from  the  broken-bone  surfaces  themselves.  The  deformity  may  also 
be  increased  by  open  wounds  of  the  soft  parts. 

Loss  of  Power. — The  loss  of  mechanical  support,  the  pain  caused 
by  movement,  and  paralysis  as  the  result  of  nerve-injury  are  the  fac- 
tors upon  which  this  symptom  depends.  It  varies  much  with  the 
character  of  the  fracture  and  the  disposition  of  the  patient.  Usually 
the  loss  of  power  is  pronounced. 

Pain. — This  symptom  depends  upon  the  wounding  of  nerves,  and 
upon  pressure  upon  the  nerves  by  bone-fragments  and  extravasated 
blood  and  serum.  Ordinarily  the  pain  of  fracture  is  not  severe,  except 
when  there  is  motion  which  permits  the  bone-edges  to  irritate  the  adja- 
cent nerve-filaments. 

Tenderness. — This  depends  upon  all  the  conditions  which  produce 
pain  and  upon  the  application  of  pressure  from  without. 

Muscular  Spasm. — As  a  result  of  the  mechanical  irritation  of  the 
muscle  itself  by  the  edges  of  bone  or  other  lacerating  or  irritating 
force,  or  by  the  injury  of  a  motor-nerve  trunk,  the  muscles  passing 
over  the  fracture  or  in  the  vicinity  of  the  fracture  tend  to  spasmodic 
contraction.  This  is  observed  especially  in  the  limbs,  and  more  par- 
ticularly about  the  humerus  and  femur,  in  which  it  almost  invariably 
causes  an  overriding  of  the  fragments. 

Shortening  of  the  Limb. — By  this  is  understood  the  shortening 
caused  by  such  overriding  as  that  described  above,  by  impaction,  or 
by  loss  of  substance. 

General  Immediate  Symptoms. — Depression. — This  depends  upon 
the  presence  of  injury  or  disease  in  other  organs,  upon  the  mental 
condition  of  the  patient,  and  upon  the  degree  of  hemorrhage  and 
injury  to  the  nerves. 

Shock. — This  is  an  exaggerated  form  of  general  depression.  It 
depends  upon  the  same  etiological  factors,  and  is  rarely  observed 
except  in  cases  of  multiple  fractures,  or  fractures  with  severe  lacera- 
tion of  soft  tissue  or  with  injury  to  other  organs. 

These  general  symptoms  are  scarcely  perceptible  in  the  ordinary 
forms  of  fracture.  The  mediate  or  later  symptoms  of  fracture  may 
also  be  divided  into  local  and  general. 

Local  Mediate  Symptoms. — In  the  course  of  a  few  hours  there 


5IO  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

always  develops  about  the  seat  of  fracture  more  or  less  edema. 
There  may  also  be  present  edema  of  the  whole  limb  below  the  fract- 
ure, as  the  result  of  obstruction  to  the  return  circulation  by  pressure 
upon  the  vessels  by  fragments  or  edges  of  bone,  by  angulation,  or  by 
the  perivascular  exudate.  When  the  exuded  serum  comes  to  the  sur- 
face, it  lifts  up  the  outer  layer  of  the  skin  and  forms  the  blebs  or  bullae 
which  are  common  about  fractures. 

Ecchymosis  is  one  of  the  most  constant  symptoms.  It  appears  a 
few  hours  after  the  injury  as  a  mottling  of  the  skin,  varying  in  color 
from  a  pale  olive  or  red  to  a  dark  maroon  or  bluish  tint.  The  blood 
comes  from  the  broken  bone  and  from  the  torn  soft  tissues.  The 
natural  tendency  is  for  the  pain  and  tenderness  gradually  to  subside, 
although  it  sometimes  happens  that,  as  a  result  of  the  pressure  of  the 
exudate,  these  symptoms  become  aggravated.  Local  rise  of  temperature 
accompanies  the  increase  of  blood-supply  and  the  increased  metabolic 
changes. 

General  Mediate  Symptoms. — Fever  develops  to  a  greater  or  less 
degree  in  all  fractures.  Hemic  or  aseptic  fever  is  present  in  all  cases, 
and  is  due  to  the  liberation  of  fibrin-ferment  from  the  extravasated 
blood,  and  the  reabsorption  of  the  same.  The  duration  of  this  fever 
depends  much  upon  the  amount  of  the  extravasation.  It  is  accom- 
panied with  no  evident  constitutional  disturbances.  Septic  fever 
depends  upon  the  presence  of  infective  organisms,  and  belongs  to 
the  consideration  of  wounds. 

Diagnosis. — Though  usually  the  diagnosis  of  fracture  is  not  dif- 
ficult, it  happens  in  many  cases  that  the  skill  of  the  surgeon  is  taxed 
to  decide  as  to  the  existence  of  a  fracture,  its  location,  or  its  variety. 
The  diagnosis  should  be  based  first  upon  the  history.  In  this  is  con- 
sidered the  question  of  predisposing  and  exciting  causes,  particular 
inquiry  being  made  as  to  the  character  of  the  injury.  The  symptoms 
should  next  be  considered.  In  many  cases  the  discovery  of  a  false  point 
of  motion  and  crepitus  cannot  be  made,  because  of  the  extreme  tender- 
ness or  strong  muscular  spasm.  These  obstacles  are  eliminated  under 
general  anesthesia.  To  elicit  these  symptoms  the  limb  should  be  firmly 
grasped  by  the  two  hands  close  together,  one  above  and  the  other 
below  the  presumed  point  of  fracture,  and  the  lower  fragment  moved 
upon  the  upper  by  transverse,  rotary,  or  angular  motion.  When  a  frac- 
ture is  near  a  joint,  the  motion  of  the  joint  may  be  confused  with  the  false 
point  of  motion.  By  fixing  the  head  of  the  bone  and  moving  the  other 
fragment  the  fracture  may  be  discovered.  True  bony  crepitus  should 
not  be  confused  with  intra-articular  grating  due  to  chronic  roughness 
or  recent  injury  of  the  joint-surfaces,  or  with  the  crepitus  of  inflamed 
bursse  or  tendon-sheaths.  Deformity  due  to  rupture  of  muscle  or  to 
local  effusion  of  serum  or  blood  following  injury  often  simulates  the 
appearance  of  fracture,  and  when  such  deformity  is  associated  with 
pain  and  tenderness  the  diagnosis  must  be  made  by  seeking  for  the 
bone-injury.  Although  pain  may  be  due  to  the  contusion,  still  when 
it  is  distinctly  and  narrowly  localized,  and  especially  when  manipula- 
tion at  a  distance  from  the  seat  of  injury  causes  pain  in  the  same 
narrow  area,  the  probability  of  the  presence  of  fracture  at  that  point 
is  very  strong.     In  certain  fractures  these  peculiar  symptoms  are  not 


FRACTURES.  511 

present  because  of  the  inaccessibility  of  the  seat  of  fracture.     This  is 
the  case,  for  example,  with  fracture  of  the  base  of  the  skull. 

In  the  diagnosis  of  fractures  a  knowledge  of  the  landmarks,  and 
especially  of  the  bony  prominences  about  the  joints,  is  of  great  impor- 
tance. The  presence  of  deformity  and  its  degree  may  be  determined 
by  comparison  of  the  injured  limb  with  the  sound  limb,  and  by  meas- 
urement of  the  bony  prominences  on  either  side  of  the  injury.  The 
rational  signs  are  determined  by  palpation  and  inspection.  By  apply- 
ing the  stethoscope  firmly  over  the  injured  bone,  and  applying  percus- 
sion, the  percussion-note  will  be  distinctly  heard  so  long  as  there  is  no 
solution  of  the  continuity  of  the  bone  between  the  stethoscope  and  the 
point  of  percussion  ;  but  if  a  fracture  intervenes,  the  sound-wave  is  lost. 
Finally,  a  shadow-picture  of  the  bone  may  be  obtained  by  means  of  the 
Rontgen  process. 

The  healing  of  fractures  is  discussed  elsewhere. 
Treatment. — The  treatment  of  fractures  is  based  upon  two  funda- 
mental principles — the  correction  of  the  deformity,  and  the  maintenance 
of  the  fragments  in  normal  apposition   until  consolidation  has  taken 
place. 

The  methods  of  replacing  the  fragments  in  their  natural  positions 
must  naturally  vary  much  with  the  location  and  character  of  the  fract- 
ure. In  many  fractures  there  is  little  or  no  displacement  whereas  in 
others  the  displacement  amounts  to  a  complete  separation  of  a  part  of 
the  bone  to  such  a  degree  as  to  cut  it  off  from  vital  connection  with 
the  rest  of  the  body.  Simple  fractures  of  the  leg  without  displacement 
are  often  changed  into  fractures  with  displacement,  or  even  into  com- 
pound fractures,  by  the  patient  attempting  to  use  the  leg  immediately 
after  the  accident.  It  is  no  uncommon  occurrence  for  simple  fractures 
to  be  converted  into  fractures  of  the  compound  variety  by  a  sharp  point 
or  edge  of  bone  penetrating  the  skin  during  the  manipulation  of  the 
limb  or  while  the  patient  is  being  transported.  It  is  therefore  impor- 
tant that  the  greatest  care  be  exercised  to  prevent  the  injury  from  being 
made  worse.  A  fractured  limb  should  be  kept  as  still  as  possible 
until  the  fractured  region  can  be  exposed.  Trousers-legs,  drawers, 
shoes,  and  stockings  should  be  cut  off,  if  their  removal  otherwise  can- 
not be  accomplished  without  undue  moving  of  the  injured  limb. 

In  the  case  of  a  complete  fracture  of  the  bones  of  the  leg  or  thigh, 
when  the  limb  is  moved,  it  should  be  supported  both  above  and  below 
the  seat  of  fracture,  and  grasped  in  such  a  way  as  to  prevent  rotation 
as  well  as  angular  motion.  When  the  patient  is  to  be  moved  from  the 
seat  of  the  accident,  motion  of  the  fragment  may  be  prevented  by 
extemporized  splints  of  board,  straw,  rolls  of  paper,  cloth,  twigs,  or 
the  injured  limb  may  be  bandaged  to  its  fellow  with  a  pillow  between. 
The  patient  should  be  carried,  if  possible  in  the  recumbent  position,  on 
a  litter.  The  subsequent  treatment  should  be  conducted  upon  a  hard 
bed — that  is,  a  bed  with  a  firm  mattress,  which  does  not  sag  with  the 
weight  of  the  body.  To  accomplish  this,  boards  should  be  placed 
between  the  mattress  and  the  springs  of  the  bed. 

In  the  correction  of  the  deformity  or  the  setting  of  the  fracture  the 
force  should  be  applied  gently,  increasing  firmly  and  gradually,  not 
quickly  and  abruptly,  until  the  desired  result  is  secured.     When  there 


512  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

is  simple  lateral  displacement,  the  limb  should  be  grasped  firmly  by  the 
left  hand  above  and  by  the  right  hand  below  the  fracture,  and,  as 
steadily  increasing  traction  is  applied,  the  lower  fragment  should  be 
slipped  over  into  place.  The  same  course  of  applying  extension  should 
be  pursued  in  correcting  fracture  with  overriding  and  with  rotary  dis- 
placement. When  the  muscular  resistance  to  the  correction  is  still 
greater,  an  assistant  should  make  counterextension  above,  and  steady 
the  leg  while  the  surgeon  with  both  hands  applies  traction  and  cor- 
recting manipulations.  Continued  marked  contraction  of  muscles,  pre- 
venting the  replacement  of  fractures,  may  be  overcome  by  tiring  out 
the  muscle  by  continuous  extension  secured  through  the  agency  of 
weights.  In  correcting  angular  displacement,  whether  the  fracture  be 
complete  or  of  the  green-stick  variety,  extension  should  be  employed 
at  the  same  time  with  the  lateral  force  which  overcomes  the  angulation. 
The  deformity  of  impacted  fracture  is  overcome  by  direct  extension. 

Ordinarily,  the  reduction  of  fractures  is  simple  and  satisfactory,  but 
there  are  certain  obstacles  which  may  intervene.  The  muscular  con- 
traction maybe  so  strong  that  it  resists  the  combined  efforts  of  surgeon 
and  assistant.  A  second  obstacle  to  correction  is  great  pain.  These 
two  symptoms  may  be  overcome  by  the  use  of  general  anesthesia. 
When  general  anesthesia  is  employed,  the  splint-material  should  be  at 
hand,  and  the  immobilization  of  the  bone  should  be  accomplished 
while  the  patient  is  still  under  the  influence  of  the  anesthetic.  Tenotomy, 
or  the  subcutaneous  division  of  resisting  muscle,  may  be  employed  to 
facilitate  reduction.  A  third  obstacle  to  reduction  is  the  interposition 
between  the  bone-fragments  of  muscle,  clot,  periosteal  tissue,  loose 
fragments  of  bone,  or  a  foreign  body.  When  a  satisfactory  reduction 
cannot  be  effected  because  of  these  things,  the  seat  of  fracture  should 
be  exposed  and  the  obstacle  removed.  It  should  be  borne  in  mind, 
however,  that  if  no  infection  is  present,  none  of  these  obstacles,  with 
the  possible  exception  of  a  foreign  body,  will  actually  prevent  the 
osseous  union  of  the  fragments,  although  they  will  retard  it,  for  they 
are  all  capable  of  becoming  involved  in  the  callus  and  incorporated  in 
the  bone-tissue.  One  of  the  great  objections  to  their  presence  is  the 
fact  that  they  render  perfect  immobilization  more  difficult,  and  thus 
conduce  to  non-bony  union.  A  final  obstacle  to  correction  is  impac- 
tion, which  may  be  so  firm  that  it  can  be  overcome  only  by  great  force. 
When  this  is  the  case,  if  the  impaction  is  not  broken  up,  solid  bony 
union  is  assured ;  but  the  surgeon  should  always  have  as  his  guide  in 
the  treatment  of  fractures  the  idea  of  the  restoration  of  the  parts  as 
nearly  as  possible  to  their  normal  state. 

The  reduction  of  fractures  should  be  attempted  as  soon  as  possible 
after  the  accident.  Every  hour's  delay  increases  the  firmness  of  the 
plastic  effusion  about  the  seat  of  the  fracture,  and  renders  reduction 
more  difficult.  If  a  fracture  with  overlapping  has  been  allowed  to  go 
uncorrected,  the  infiltration  with  exudate  of  the  surrounding  tissues  so 
destroys  their  elasticity  that  reduction  without  operation  maybe  impos- 
sible ;  nor  may  the  surgeon  expect  to  overcome  this  resistance  by 
general  anesthesia. 

Before  proceeding  further  with  the  treatment,  the  condition  of  the 
skin  should  be  looked  to.     Excoriations  should  be  covered  with  mild 


FRACTURES.  5  I  3 

antiseptic  ointment  spread  upon  dry  gauze.  Serous  blebs  should  be 
snipped  with  scissors  at  their  most  dependent  part,  and  all  of  the  fluid 
evacuated.  The  cuticle  need  not  be  removed,  but  should  be  covered 
with  a  bland  powder,  such  as  zinc  oxid,  and  a  few  layers  of  dry  gauze. 
The  surface  should  be  examined  for  prominent  points  of  bone  beneath 
the  skin,  which  might  penetrate  and  render  the  fracture  compound.  If 
such  a  point  is  discovered,  further  manipulation  should  be  resorted  to 
with  the  view  of  securing  a  more  perfect  reduction.  When  this  cannot 
be  accomplished,  the  danger  may  be  lessened  by  applying  a  protecting 
pad  of  gauze.  Care  should  be  taken  that  the  compression  is  made 
not  directly  upon  the  threatening  point,  but  over  the  neighboring  bone 
with  which  it  is  connected.  No  encircling  bandage  should  ever  be 
applied  next  to  the  skin  beneath  a  splint,  unless  the  rest  of  the  limb 
beyond  is  completely  covered  by  bandage  equally  firm. 

The  immobilization  of  the  fragments  is  accomplished  by  one  of  the 
following  means  :  By  position,  by  splints,  by  extension,  or  by  direct 
fixation.  In  certain  cases,  however,  the  deformity  remains  corrected 
without  the  use  of  any  of  these  artificial  methods.  The  placing  of  the 
parts  in  a  certain  position — as,  for  example,  the  use  of  the  double 
inclined  plane  in  fractures  of  the  leg,  or  the  dorsal  recumbent  position 
of  the  body  in  fractures  of  the  clavicle — often  suffices  to  retain  the 
bones  in  the  desired   apposition. 

Before  the  application  of  a  permanent  splint,  the  parts  to  be  covered 
should  be  cleansed  with  soap  and  water.  As  a  general  rule,  it  is  well 
to  immobilize  the  joints  immediately  above  and  below  the  fracture.  The 
greatest  care  should  be  taken  to  avoid  local  pressure  by  the  splint- 
apparatus.  Pressure  should  be  evenly  distributed.  Prominent  points 
which  may  receive  undue  pressure  from  the- splint  should  be  thickly 
covered  with  soft  padding.  A  splint  which  has  been  properly  applied 
should  give  to  the  patient  a  feeling  of  comfort  and  support  to  the  part. 
The  persistent  continuance  of  pain  means  that  something  is  wrong,  and 
the  splint  should  be  removed. 

Of  the  materials  used  for  splints,  the  most  valuable  is  plaster  of  Paris, 
the  introduction  of  which  has  marked  an  era  in  the  treatment  of  fract- 
ures. In  most  cases  it  is  best  employed  in  the  form  of  the  plaster 
bandage.  This  consists  of  a  roller  bandage  of  coarse-meshed  cotton 
cloth,  in  the  meshes  of  which  dry  plaster  is  held.  These  bandages  are 
made  by  drawing  the  strip  of  bandage  through  the  plaster,  and  loosely 
winding  it,  so  that  when  the  bandage  is  completely  rolled  there  is  a  rich 
amount  of  plaster  between  its  folds  and  held  within  the  meshes  of  the 
fabric.  These  bandages  may  be  made  in  any  width,  but  preferably  from 
2  to  4  inches  (5  to  10  cm.).  Plaster  of  Paris  absorbs  water  from  the 
atmosphere  in  the  course  of  time,  and  when  slightly  hydrated  in  this 
way  does  not  harden  well.  Unless  the  plaster  has  been  protected  from 
the  air  by  keeping  in  a  tightly  sealed  receptacle,  it  should  be  sub- 
jected to  dry  heat  before  using.  When  the  bandages  are  kept  already 
made  up,  they  may  be  dehydrated  by  placing  them  in  the  dry  heat  of 
an  ordinary  kitchen  oven.  When  ready  for  use  the  roller  bandage 
should  be  put  in  sufficient  water  to  cover  it,  the  bandage  standing  on 
end  to  allow  the  bubbles  of  air  to  escape.  After  having  become 
thoroughly  hydrated,  the  excess  of  water  should  be  squeezed  out, 
33 


5  H  IXTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

the  ends  of  the  bandage  being  covered  by  the  hands  to  prevent  the 
escape  of  the  plaster.  It  is  usually  desirable  that  the  plaster  harden 
as  quickly  as  possible.  To  facilitate  this,  hot  water  to  which  salt  has 
been  added,  an  ounce  to  the  quart  of  water,  should  be  used. 

Before:  applying  the  plaster  bandage,  the  skin  should  be  smoothly 
and  evenly  covered  with  cotton  wadding  or  flannel  bandage.  If  the 
person  applying  the  plaster  is  skilled  in  its  use,  the  best  covering  for  a 
limb  is  a  seamless  white  cotton  stocking,  upon  which  the  plaster  may 
be  directly  applied.  In  the  case  of  an  ordinary  fracture  of  both  bones 
of  the  leg,  the  skin  having  been  cleansed  and  covered,  the  patient 
should  be  placed  upon  a  narrow  table ;  the  assistant,  standing  on  the 
side  opposite  the  surgeon,  grasps  the  foot  firmly  in  his  right  hand,  while 
the  left  hand  supports  the  leg  at  a  point  just  above  the  seat  of  fracture. 
The  desired  position  having  been  secured,  a  plaster  bandage  4  inches 
(10  cm.)  wide  is  applied  about  the  leg  at  the  seat  of  fracture,  gradually 
extending  above  and  below  as  far  as  the  knee-  and  ankle-joint.  A  nar- 
rower bandage  may  then  be  applied  to  the  foot  and  ankle,  and  extend- 
ing up  over  the  fracture.  This  should  be  followed  by  a  wide  bandage 
involving  the  leg  and  extending  up  over  the  knee.  After  this  the 
bandages  may  be  continued  until  the  desired  thickness  has  been 
secured.  By  applying  some  long  spiral  turns  or  a  few  longitudinal 
strips,  and  by  rubbing  well  together  the  layers  as  they  are  applied,  the 
degree  of  firmness  of  the  splint  maybe  much  increased  and  the  amount 
of  material  required  diminished.  The  greatest  care  should  be  taken 
that  the  pressure  made  by  the  dressing  is  even.  The  bandage  should 
always  be  applied  perfectly  flat,  and  not  with  one  edge  drawn  more 
tightly  than  the  other.  The  splint  may  be  strengthened  by  incorpo- 
rating in  it  strips  of  wood-shavings,  wooden  splints,  or  strips  of  wire 
gauze  or  thin  metal. 

A  substitute  for  plaster  of  Paris  is  silicate  of  soda.  Bandages 
impregnated  with  a  solution  of  this  material,  after  they  are  once  hard- 
ened, are  not  softened  by  moisture.  The  disadvantage  is  that  it  makes 
a  less  firm  dressing  than  the  plaster.  When  it  is  desired  to  render  a 
plaster  splint  impervious  to  water,  it  may  be  coated  with  a  solution  of 
silicate  of  soda  or  with  varnish. 

Moulded  splints  are  made  of  soft  materials  which  harden  after 
having  been  pressed  against  the  part  and  made  to  conform  to  the 
desired  shape.  For  this  purpose  several  layers  of  fabric,  cut  to  the 
desired  length  and  width,  and  impregnated  with  a  solution  of  plaster 
of  Paris  while  in  a  pliable  state,  are  pressed  against  the  limb  and  held 
in  place  by  a  bandage  or  by  straps.  Papier-mache  and  felt  are  also  used 
in  this  manner.  Splints  of  this  sort  are  usually  made  in  the  form  of  a 
gutter,  so  that  they  may  be  removed  at  pleasure.  The  complete  plas- 
ter-bandage envelope  may  also  be  converted  into  a  removable  or  a 
gutter-splint  by  cutting  it  into  two  parts  by  means  of  an  anterior  and  a 
posterior  incision  or  by  lateral  incisions.  One  or  both  of  these  parts 
may  be  used  ;  or  they  may  be  united,  corset-like,  by  laces  and  hooks. 

Non -plastic  splints  are  made  of  wood  and  metals.  Of  the  former  are 
the  thin  elastic  strips  of  soft  wood,  called  coaptation-splints,  and  the 
heavier  straight  splints.  The  fracture^box,  which  used  to  figure  promi- 
nently in  surgery,  has  quite  gone  out  of  use.     A  great  variety  of  metal- 


FRACTURES.  515 

lie  splints  are  made  for  the  special  fractures  ;  but  plaster  of  Paris  can  be 
used  in  the  place  of  most  of  these.  The  ambulatory  splint  for  the 
treatment  of  fractures  of  the  lower  extremity  is  described  elsewhere. 

When  the  tendency  to  overriding  of  the  fragments  is  persistent,  the 
application  of  permanent  extension  becomes  necessary.  This  is  accom- 
plished by  attaching  a  weight  to  the  extremity,  by  elastic  extension,  or 
by  using  the  weight  of  the  limb  itself  to  overcome  the  deformity.  The 
methods  of  applying  extension  will  be  described  in  treating  of  the 
special  fractures. 

In  certain  cases,  despite  the  best  efforts,  the  fragments  cannot  be 
made  to  remain  in  satisfactory  apposition.  When  all  other  resources 
have  failed,  the  well-equipped  surgeon  is  justified  in  exposing  the  seat 
of  fracture  and  applying  such  local  treatment  as  the  conditions  require. 
The  incision  of  operation  often  liberates  an  amount  of  blood  and  serum, 
the  presence  of  which  has  been  an  obstacle  to  reduction.  The  removal 
of  soft  tissues  which  have  fallen  between  the  bone-ends  can  then  be 
accomplished.  Often  nothing  further  is  required.  But  when  the  sur- 
geon feels  that  neither  splints  nor  extension  will  suffice  to  hold  the 
fragments  in  place,  he  should  proceed  to  the  direct  fixation  of  the  bone- 
ends.     Direct  suturing  or  binding  of  the  bone-ends  by  means  of  wire, 


Fig.  219. — Fracture  of  tibia  immobilized  by  clamp-and-screw  apparatus  (Parkhill). 

silkworm-gut,  or  chromicized  gut  is  often  indicated.  Nails  and  pegs 
of  bone,  ivory,  or  metal  may  be  used ;  or  bone  or  metallic  plates,  or 
bone  ferrules  or  cylinders  ;  or  external  metal  plates  controlling  the 
deeper  bone  fragments  by  long  screws,  as  in  the  method  of  Parkhill 
(Fig.  219). 

Bircher  has  introduced  a  cylinder  of  ivory  into  the  medullary  canal 
for  the  purpose  of  preventing  lateral  displacement ;  and  with  the  same 
view,  Senn  has  used  a  hollow  perforated  bone-cylinder.  Senn  has 
advocated  the  use  of  ferrules  made  from  the  tibia  and  femur  of  the  ox 
for  holding  oblique  fractures  in  position.  The  overlying  wound  is 
closed  and  the  foreign  material  allowed  to  heal  in.  When  metals  are 
used,  they  may  be  exposed  and  removed  at  a  later  operation.  In  the 
case  of  simple  wire  sutures,  the  ends  may  be  left  long  enough  to  pro- 
ject through  the  wound,  which  is  closed  throughout  and  covered  by 
copious  dressings.  With  the  ends  as  a  guide,  the  wire  may  be  cut  and 
easily  removed  after  it  has  served  its  purpose. 

In  dealing  with  comminuted  fractures  with  irreducible  displacement, 
after  extension,  manipulation,  anesthesia,  and  tenotomy  have  failed,  the 
same  general  principles,  stated  above,  apply.  Here  the  surgeon  often 
has  to  do  with  loose  fragments  of  bone  which  have  become  entirely 
separated,  and  often  so  displaced  as  to  form  the  chief  impediment  to 


5l6  INTERNATIONAL    TEXT-BOOK   OE  SURGERY. 

reduction.  Such  fragments  should  usually  be  removed.  If  replaced 
and  allowed  to  remain,  their  tendency  is  to  become  exfoliated,  though 
this  tendency  is  being  overcome  by  the  perfection  of  surgical  technic. 
After  the  removal  of  a  large  fragment  of  bone  from  the  leg  or  fore- 
arm, the  parallel  bone  prevents  the  bone-ends  coming  together.  In 
such  case  an  equal  amount  may  be  resected  from  the  sound  bone,  if 
the  amount  of  bone  required  to  be  removed  is  not  so  great  as  to 
destroy  the  usefulness  of  the  muscles.  When  the  gap  is  too  great  to  be 
thus  treated,  it  may  be  filled  with  bone  from  a  foreign  source,  or  treated 
by  an  osteoplastic  lengthening  of  the  injured  bone. 

The  involvement  of  a  joint  by  a  fracture  adds  another  element  of 
importance.  As  a  result  of  the  injury  to  the  joint,  there  is  an  intra- 
articular effusion  of  blood  and  serum,  and  the  traumatic  reaction  about 
the  line  of  fracture  causes  the  formation  of  plastic  exudate  upon  the 
synovial  surface.  For  this  reason,  ankylosis,  due  to  the  adhesions  of 
the  new-formed  plastic  exudate  to  the  opposing  synovial  surface,  is 
prone  to  develop  when  the  joint  is  kept  immobilized  for  any  con- 
siderable time.  Moreover,  motion  of  the  joint  immediately  after  the 
injury  increases  the  amount  of  exudate  and  effusion,  and  thus 
increases  the  liability  to  ankylosis.  The  guiding  principle,  there- 
fore, in  the  treatment  of  such  fractures,  is  immediate  and  complete 
immobilization,  and  thereafter,  carefully  applied  passive  motion  as 
soon  as  the  traumatic  reaction  has  subsided,  and  the  consolidation 
of  the  fracture  has  become  sufficiently  advanced  to  hold  the 
fragments  securely  together.  The  early  application  of  the  ice-bag 
will  diminish  the  effusion  of  fluid  into  the  joint.  Evenly  applied  press- 
ure by  means  of  a  flannel  bandage  has  the  same  effect,  but  is  less 
desirable  during  the  first  few  days.  Later,  at  the  end  of  one  or  two 
weeks,  when  the  acute  reaction  has  subsided,  massage,  heat,  and  press- 
ure will  hasten  the  removal  of  the  effused  fluid.  If  the  amount  of 
fluid  is  very  great,  or  if  these  methods  fail  to  cause  its  absorption,  the 
joint  must  be  aspirated,  or  incised  and  cleaned  out  if  the  distention  is 
due  to  blood-clot.  When  immobilizing  such  a  joint,  the  surgeon  should 
always  have  in  mind  the  possibility  of  the  danger  of  ankylosis  ;  and, 
when  consistent  with  the  treatment  of  the  fracture  itself,  he  should  place 
the  joint  in  such  a  position  as  shall  render  the  limb  the  most  useful 
should  this  untoward  result  occur.  Ankylosis  should  later  be  over- 
come by  carefully  applied  passive  motion. 

The  treatment  of  compound  fractures  is  based  upon  the  same 
principles  as  govern  the  treatment  of  wounds,  plus  the  principles 
which  have  already  been  laid  down  for  the  treatment  of  fractures. 
Some  of  the  salient  points  of  these  two  conditions  may  be  briefly 
mentioned.  If  a  temporary  dressing  is  to  be  applied,  the  wound  should 
be  irrigated  by  introducing  between  its  lips  an  irrigating  point  and 
washing  it  out  with  a  i  :  2000  sublimate  or  other  antiseptic  solution. 
Over  this  should  be  placed  a  copious  moist  dressing  of  gauze  wrung 
out  in  the  same  solution,  followed  by  the  temporary  splint.  After 
the  patient  has  been  removed  to  the  place  for  further  treatment 
— preferably  the  hospital  operating-room — and  placed  upon  the  table, 
the  region  about  the  wound  should  be  exposed  widely.  In  the  more 
severe  cases  requiring  considerable  manipulation,  it  is  best  to  administer 


FRACTURES.  Sl7 

a  general  anesthetic  before  the  temporary  splint  is  removed.  If  the 
fracture  is  one  of  the  leg,  it  should  be  rested  upon  a  sand-bag,  which 
can  be  made  to  conform  in  shape  to  the  posterior  contour  of  the  limb. 
The  surrounding  field  should  be  covered  with  sterilized  towels.  A  bit 
of  gauze  should  be  held  against  the  wound  while  the  whole  leg  is 
thoroughly  scrubbed  with  soap  and  water,  shaved,  and,  especially  the 
region  just  about  the  wound,  cleansed  with  ether  and  a  i  :  iooo 
solution  of  sublimate.  The  wound  should  again  be  thoroughly  irri- 
gated with  antiseptic  solution,  and  its  extent  and  the  character  of  the 
fracture  explored. 

If  the  injury  to  the  soft  parts  is  but  slight,  the  displacement  of 
bone  inconsiderable,  and  the  amount  of  hemorrhage  and  effusion  small, 
the  wound  may  be  partly  sutured,  leaving  always  a  liberal  opening  for 
drainage.  Into  this  may  be  introduced  a  strip  of  sterilized  gauze,  and 
the  whole  covered  with  a  moist  sterile  gauze  compress.  In  no  case  is 
it  recommended  to  seal  the  wound  of  a  compound  fracture  hermetically. 

Should  the  examination  show  that  there  is  considerable  injury  to  the 
soft  tissues,  irreducible  displacement,  or  the  presence  of  foreign  matter, 
the  surgeon  should  freely  enlarge  the  wound,  or  make  such  new  wounds 
as  shall  give  the  best  access  to  the  seat  of  injury.  There  should  be  no 
timidity  in  multiplying  the  number  of  longitudinal  wounds,  for  in  these 
cases  abundant  provision  for  drainage  is  most  desirable.  It  often 
becomes  necessary  to  repair  ruptured  muscles,  tendons,  and  nerves,  or 
to  ligate  blood-vessels.  All  foreign  material  should  be  removed  with 
most  scrupulous  exactness,  frayed  and  damaged  bits  of  fascia  and  muscle 
should  be  cut  away,  and  loose  fragments  of  bone  should  be  removed, 
the  bone  being  dealt  with,  if  necessary,  by  the  methods  of  direct 
fixation  described  above.  In  closing  the  wounds,  the  provisions  for 
drainage  should  be  abundant.  It  is  well  in  these  more  severe  cases  to 
apply  a  large  absorbent  dressing,  and  immobilize  the  bone  by  a  tem- 
porary splint.  At  the  end  of  four  or  six  days — sooner  or  later,  varying 
with  the  degree  of  the  patient's  temperature  and  other  signs— this 
splint  should  be  removed  and  the  wound  dressed.  Drainage-tubes 
should  be  irrigated  through  and  through  to  insure  their  patency,  and 
gauze  drains  should  be  renewed  or  removed.  From  this  time  on  the 
surgeon  should  be  guided  in  the  dispensing  with  drainage,  in  the 
shortening  of  drains,  in  the  instituting  of  new  drainage,  in  the  applica- 
tion of  secondary  sutures,  and  in  the  management  of  the  wound  by 
the  general  principles  for  the  treatment  of  wounds. 

At  as  early  a  stage  as  possible  a  permanent  splint  should  be  applied, 
with  suitable  provision  for  dressing  the  wound  without  removing  the 
splint.  A  small  dry  dressing,  quadrilateral  in  shape,  having  been 
applied,  and  the  dressing  covered  with  the  impervious  oiled  muslin  of 
the  shops,  the  plaster  bandage  should  be  put  on  over  all.  Before  the 
plaster  has  become  thoroughly  hardened,  a  fenestrum,  outlining  the 
dressing,  should  be  cut.  The  oiled  muslin  should  then  be  cut  through 
and  reflected  back  over  the  four  edges  of  the  fenestrum  in  such  a  way 
as  to  prevent  the  moisture  of  the  dressings  softening  the  plaster. 

If  more  than  one  fenestrum  is  required,  or  if  the  fenestrum  must 
involve  more  than  half  of  the  circumference  of  the  splint,  it  should  be 
strengthened  by  incorporating  into  it  a  strip  of  basswood  or  a  metal 


5  IS  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

bar.  The  same  end  can  be  accomplished  by  introducing  an  iron  bar 
which  passes  down  as  far  as  the  fenestrum  and  then  leaves  the  plaster 
bandage  and  curves  over  the  opening  to  re-enter  it  below. 

Three  conditions  arising  in  compound  fractures  justify  immediate 
amputation:  (i)  injury  to  the  blood-vessels  so  great  as  to  cause  the 
death  of  the  part;  (2)  uncontrollable  suppuration,  and  (3)  wide  loss  of 
bone  substance.  It  is  often  evident  at  the  first  examination  that  the 
injury  to  the  vessels  has  been  so  great  that  the  parts  below  the  wound 
must  become  gangrenous.  In  such  cases  the  extremity  is  found  to  be 
cold  and  to  present  a  gradually  increasing  livid  color.  The  main  ves- 
sels may  be  found  to  be  divided  or  thrombosed.  Pressure  upon  the  skin 
or  nails  does  not  show  the  return  of  blood  into  the  capillaries  of  the 
area  from  which  it  was  expressed.  In  such  cases  amputation  should 
be  done.  On  the  other  hand,  examination  may  show  the  extremity 
to  be  cold  and  the  main  vessel  pulseless,  but  if  all  the  signs  of  death 
of  the  part  are  not  present,  the  surgeon  should  endeavor  to  save  the 
limb,  inflicting,  as  he  proceeds  with  the  examination  and  dressing,  the 
least  possible  traumatism,  and,  finally,  applying  the  bandages  as  loosely 
as  possible.  In  all  cases  an  effort  should  be  made  to  preserve  the 
extremity,  unless  it  is  unquestionably  beyond  saving.  Nor  even  then 
is  immediate  amputation  always  called  for.  If  the  patient  is  suffering 
from  shock,  extreme  depression,  or  anemia,  or  if  other  conditions  are 
present  which  render  the  continuation  of  operative  procedure  extra- 
hazardous, the  parts  should  be  thoroughly  cleansed,  hemostasis 
secured,  a  large,  moist,  antiseptic  dressing  applied,  and  further  opera- 
tion deferred.  If  circular  compression  is  used  to  control  the  hemor- 
rhage previous  to  amputation,  it  should  be  applied  as  low  down  as 
possible,  preferably  directly  over  the  wounds,  as  the  vitality  of  the 
tissues  below  the  pressure  is  greatly  impaired,  and  flaps  involving  such 
tissue  are  prone  to  slough. 

When  in  a  compound  fracture,  notwithstanding  free  and  wide  inci- 
sions, abundant  drainage,  and  irrigation,  because  of  some  constitutional 
or  local  condition,  uncontrollable  suppuration  persists,  and  septicemia 
threatens  the  life  of  the  patient,  amputation  well  above  the  suppurating 
area  should  be  performed.  The  same  operation  is  necessary  when, 
through  local  disturbance  to  the  blood-supply,  suppuration  causes  a 
gangrene  of  the  extremity.  Amputation  is  also  indicated  in  cases  in 
which  there  is  so  much  destruction  of  bone  that,  in  order  to  bring  the 
bone-ends  together,  the  limb  must  be  shortened  to  such  a  degree  and 
the  soft  tissue  so  folded  as  either  to  render  the  limb  less  useful  than  an 
artificial  substitute,  or  to  give  rise  to  gangrene  because  of  obstruction 
to  the  circulation  through  angulation  of  the  vessels.  In  cases  such  as 
this  an  effort  should  be  made  to  save  the  limb  by  means  of  an  osteo- 
plastic operation  or  by  the  transplantation  of  bone  to  fill  the  defect. 
Among  the  greatest  triumphs  of  modern  surgery  is  the  saving  of  limbs 
which  are  the  seat  of  a  compound  fracture. 

Although  every  effort  should  be  made  in  the  line  of  conservative 
surgery,  still  there  is  a  fourth  class  of  cases  in  which  amputation  is 
indicated.  These  are  the  cases  in  which,  in  order  to  preserve  the  limb, 
a  veiy  long  and  trying  period  of  treatment  must  elapse,  with  continu- 
ous suppuration  and  confinement,  all  of  which  must  have  a  depressing 


FRACTURES.  519 

effect  upon  the  health  of  the  patient,  and  end  in  securing  onlv  an 
imperfect  limb.  The  age,  sex,  and  occupation  of  the  patient,  the  loca- 
tion of  the  injury,  and  the  adaptability  of  prosthetic  apparatus  to  the 
particular  part,  should  be  taken  into  consideration  ;  and,  finally,  with  a 
full  understanding  of  the  case,  the  patient  himself  may  be  called 
upon  to  elect  the  course  which  shall  be  followed. 

Complications. — By  the  complications  of  fracture  are  understood 
the  less  characteristic  symptoms,  or  the  rarer  conditions  which  may 
arise,  but  which  do  not  occur  with  sufficient  frequency  to  be  regarded 
as  symptoms. 

Immediate  Complications. — Comminution,  impaction,  and  disloca- 
tion may  be  mentioned  as  complications.  Injuries  to  the  soft  parts — 
muscles,  viscera,  vessels,  and  nerves — often  demand  special  treatment. 
Lacerated  muscle  often  requires  suturing ;  pulpified  muscle  should  be 
cut  away.  Injuries  to  the  viscera,  such  as  the  brain  in  fractures  of  the 
skull,  and  the  bladder  in  fractures  of  the  pelvis,  are  dealt  with  accord- 
ing to  rules  laid  down  elsewhere.  Large  blood-vessels  are  frequently 
lacerated  either  by  the  force  which  causes  the  fracture  or  by  a  sharp 
edge  of  bone  from  within.  Such  laceration  may  give  rise  to  an  exten- 
sive effusion  of  blood  into  the  tissues,  showing  itself  in  the  form  of 
swelling  and  discoloration  or  localized  hematoma.  If  the  swelling  is 
considerable,  or  if  the  pressure  from  the  extravasated  blood  is  so  great 
as  to  hinder  the  circulation  materially  in  the  limb  beyond,  the  vessel 
should  be  exposed  and  the  bleeding  point  ligated.  Traumatic  aneurysm 
and  aneurysmal  varix  are  thus  sometimes  associated  with  fractures. 
Laceration  of  lymphatic  trunks  causes  a  localized  lymph-edema  which 
may  require  surgical  treatment.  The  pressure  of  displaced  bone 
against  the  vessels  may  impede  the  circulation  to  such  a  degree  as  to 
threaten  gangrene.  Injury  to  the  nerves  at  the  time  of  fracture  is  no 
uncommon  complication.  It  may  be  in  the  form  of  laceration,  com- 
pression, or  stretching  of  the  nerve.  All  of  these  are  accompanied 
with  pain  and  more  or  less  disturbance  in  the  parts  beyond.  If  paral- 
ysis is  present,  and  the  traumatism  has  been  great  enough  to  have 
caused  laceration,  though  the  examination  shows  no  evidences  of  press- 
ure as  a  cause  of  the  paralysis,  the  surgeon  is  justified  in  exposing  the 
nerve  with  the  view  of  discovering  the  character  of  its  injury,  and 
suturing  the  ends  if  laceration  is  discovered. 

Mediate  Complications. — The  mediate  or  later  complications  are 
those  which  may  come  on  any  time  during  the  process  of  healing. 
They  constitute  a  large  catalogue  of  widely  different  conditions! 

The  pressure  from  the  effusion  of  serum  may  be  so  great  as  to  ob- 
struct the  circulation  to  such  a  degree  that  gangrene  of  the  parts  beyond 
is  threatened.  Such  extreme  swelling  may  be  relieved  by  multiple 
longitudinal  incisions,  allowing  the  serum  to  escape,  followed  by  eleva- 
tion of  the  limb.  After  a  limb  has  been  bandaged  for  a  long  time, 
edema  is  observed  on  the  removal  of  the  bandage  because  of  the  vaso- 
motor paralysis.  The  vessels  gradually  regain  their  tone,  however, 
and  the  swelling  subsides.  Usually  the  edema  due  to  fracture  does 
not  call  for  any  special  treatment.  The  firmly  and  evenly  applied 
bandage  from  the  toes  or  fingers  up  usually  suffices  to  control  the 
swelling.     The  sooner  and  the  more  firmly  a  fracture  is  immobilized, 


520  INTERNATIONAL    TEXT-BOOK   OE  SURGERY. 

the  less  will  be  the  swelling.  This  is  a  rule  which  the  surgeon  should 
always  have  in  mind. 

Inflammatory  swelling  is  amenable  to  the  treatment  described  else- 
where. Ulceration,  sloughing,  and  gangrene,  due  to  the  constriction 
of  bandages  or  pressure  of  splints,  are  dangers  always  to  be  guarded 
against.  Dressing  materials  should  never  be  wound  circularly  about 
a  limb,  but  should  be  applied  lightly  in  folds  or  longitudinally.  The 
bandage  which  holds  the  dressings  should  never  be  tighter  than  the 
flannel  bandage  beyond.  The  tips  of  the  fingers  and  toes  should 
always  be  left  exposed,  in  order  that  the  condition  of  their  circulation 
may  be  observed.  It  should  always  be  borne  in  mind  that  the  shock 
which  a  fractured  limb  has  received  has  diminished  its  vitality.  Patients 
suffering  with  diabetes  are  especially  liable  to  gangrene  following  fract- 
ure, as  are  those  with  atheromatous  vessels  and  cardiac  disease.  When 
gangrene  appears,  the  surgeon  should  determine  its  cause ;  and  when 
this  is  not  removable,  the  further  treatment  must  depend  upon  the 
absence  or  presence  of  infection.  Thrombosis  occurring  in  a  large 
vascular  trunk,  as  the  result  either  of  traumatism  to  the  inner  coat  of 
the  vessel  or  of  inflammation  extending  thereto,  is  a  prolific  cause  of 
gangrene.  Thrombosis  occurring  in  a  vein  may  be  the  cause  of  edema 
or  of  gangrene. 

Fat-embolism  is  a  condition  peculiar  to  fractures,  and  comes  on  about 
the  third  day.  It  is  due  to  the  liberation  of  fat  from  the  medulla  of 
the  broken  bone,  its  entrance  into  the  torn  veins,  and  its  transmis- 
sion through  the  circulation  to  the  various  organs  of  the  body.  Ag- 
gregations of  globules  of  fat  are  found  plugging  capillaries  of  the 
lungs,  brain,  kidneys,  and  other  organs.  So  long  as  the  infarctions 
thus  produced  are  not  infective,  or  do  not  shut  off  the  blood-supply 
from  any  considerable  part  of  a  vital  organ,  as  is  usually  the  case,  the 
occurrence  is  of  little  moment.  Rarely,  however,  a  cerebral  vessel  of 
considerable  size  or  a  large  number  of  smaller  vessels  thus  become 
obstructed,  and  the  patient  dies  usually  about  the  fourth  day.  It  is 
probable  that  in  every  fracture  some  fat  enters  the  circulation.  The 
cases  with  severe  comminution  are  those  in  which  the  condition  is 
most  apt  to  be  of  a  serious  character.  Dyspnea,  Cheyne-Stokes  res- 
piration, and  the  signs  of  cerebral  embolism  have  been  observed  in 
these  cases.  Blood-embolism  originates  by  a  thrombus  being  swept 
loose  from  a  vein  at  the  seat  of  fracture,  carried  to  the  heart,  and 
thence  thrown  into  the  pulmonary  circulation.  In  the  cases  in  which 
this  accident  has  occurred,  the  first  sign  was  the  sudden  appearance  of 
extreme  dyspnea  about  the  third  week  after  the  injury.  When  the 
embolus  has  been  large  enough  to  plug  a  pulmonary  trunk  of  con- 
siderable size,  the  patient  has  died  a  few  moments  after  the  attack 
began. 

Muscular  spasm,  which  has  already  been  spoken  of  among  the 
symptoms  of  fracture,  often  persists  during  the  period  of  treatment, 
and  requires  to  be  overcome  by  constant  traction  or  some  of  the 
methods  described  above.  Other  complications  are  acute  osteomye- 
litis and  suppurative  osteitis.  Necrosis  of  bone  is  a  common  compli- 
cation in  compound  fractures.  This  is  often  manifested  in  the  form 
of  a  superficial  exfoliation  of  thin  plates  or  spicules  of  bone.     Two 


FRACTURES.  521 

conditions  usually  contribute  to  this — denudation  of  the  bone  of  peri- 
osteum, and  the  presence  of  suppuration.  Sometimes  the  necrosis 
involves  the  whole  thickness  of  the  bone  ;  often  the  two  ends  of  the 
fragments  become  exfoliated.  When  it  is  evident  to  the  surgeon,  from 
the  white  appearance  of  an  area  of  bone,  from  its  failure  to  give  rise  to 
granulation-tissue  or  to  become  attached  to  the  surrounding  structures, 
that  a  particular  part  of  the  bone  has  become  devitalized,  he  may  know 
that  the  wound  which  is  connected  with  it  will  continue  to  discharge 
until  the  dead  portion  has  become  exfoliated  by  the  slow  natural  proc- 
esses or  until  it  has  been  removed  by  artificial  means.  In  order  to 
hasten  the  healing  in  such  cases,  the  diseased  bone  may  be  chiselled 
or  sawed  away  until  healthy  bone,  as  evidenced  by  the  color  or  by  the 
bleeding,  is  exposed. 

Stiffness  of  joints  occurs  as  a  result  of  prolonged  immobilization, 
involvement  of  the  joint  in  the  fracture,  or  from  extra-articular  mechan- 
ical causes.  The  time  required  for  a  joint  to  regain  its  suppleness 
after  prolonged  immobilization  varies  greatly  with  different  circum- 
stances. At  the  best  it  is  always  a  matter  of  considerable  time,  and  is 
greatly  delayed  in  the  case  of  old  and  rheumatic  persons.  The  gen- 
eral rule  of  liberating  joints  from  confinement  by  shortening  or  remov- 
ing splints  as  soon  as  possible  should  be  followed.  Gradually  applied 
passive  and  active  motion  should  be  instituted  in  all  cases  as  early  as 
the  other  conditions  will  permit.  In  this,  massage  is  a  most  valuable 
measure.  Atrophy  of  the  limb  occurs  in  all  fractures  involving  these 
members,  chiefly  as  the  result  of  disuse.  From  this  cause  it  often 
happens  that  a  plaster  bandage  which  at  first  was  snug  becomes  so 
loose  that  it  is  no  longer  adequate  for  the  perfect  immobilization  of  the 
limb.  The  atrophy  involves  not  only  the  muscular  tissue,  but  the  con- 
nective tissue  as  well;  and  the  diminution  in  the  blood-supply,  and  hence 
the  lessened  amount  of  fluid  in  the  limb,  makes  the  atrophy  seem 
even  more  pronounced.  When  the  limb  is  again  brought  into  use, 
the  atrophy  gradually  disappears.  The  affected  tissue  may  be  more 
quickly  restored  to  its  normal  condition  by  the  application  of  mas- 
sage. Pain  about  the  seat  of  fracture  or  along  the  distribution  of  a 
nerve  may  be  a  continuation  of  that  symptom,  or  it  may  be  due  to  the 
involvement  of  a  neVve  in  callus  or  in  inflammatory  exudate,  or  to  the 
pressure  from  some  of  the  above-described  pressure-producing  condi- 
tions. Paralysis  of  muscles  below  the  fracture  is  due  to  the  same  causes. 
The  treatment  consists  in  relieving  the  nerve  from  pressure.  Often 
this  can  be  accomplished  only  by  cutting  down  upon  the  nerve  and 
freeing  it  from  the  compressing  tissue,  or  by  removing  the  bony  promi- 
nence which  may  be  pressing  against  it. 

Excessive  callus  or  excessive  new  connective-tissue  deposit  is  a  condi- 
tion resulting  from  imperfect  immobilization  or  severe  comminution. 
It  is  often  found  about  the  femur  and  humerus,  because  of  the  difficulty 
in  thoroughly  immobilizing  these  bones.  It  is  brought  about  by  the 
repeated  breaking  and  straining  of  the  newly  formed  circulatory  chan- 
nels. As  a  result  of  these  traumatisms,  new  plastic  material  is  poured 
out,  and  the  surrounding  muscles,  and  even  tendon-sheaths,  nerves, 
and  vessels,  become  infiltrated  with  young  connective-tissue  cells.  The 
swelling  and  induration  thus  produced  often  give  rise  to  the  suspicion 


5—  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

of  malignant  tumor  developing  at  the  scat  of  fracture,  and  microscopic 
examination  of  such  tissue  requires  very  careful  study  to  differentiate 
it  from  certain  forms  of  small  round-cell  sarcoma.  The  healing  of  a 
fracture  of  the  femur,  for  example,  may  have  progressed  to  a  state  of 
apparently  satisfactory  consolidation  ;  the  patient  is  allowed  to  use  the 
limb  prematurely;  he  complains  suddenly  of  pain  and  a  feeling  of 
weakness  in  the  affected  part ;  swelling  about  the  callus  begins,  and 
in  the  course  of  a  few  days  the  callus  seems  to  have  become  greatly 
enlarged.  This  is  the  picture  of  re-fracture  or  giving  way  of  a  poorly 
consolidated  callus,  with  the  subsequent  pouring  out  of  an  excessive 
or  compensator)-  plastic  exudate.  Here  again  the  statement  may  be 
made  that  the  more  perfect  the  immobilization  of  a  fracture  and  the 
sooner  immobilization  is  applied,  the  less  will  be  the  swelling. 

Certain  morbid  growths  appearing  at  the  seat  of  fracture  may  be 
classed  as  complications,  although  usually  such  developments  take 
place  after  full  consolidation  has  been  reached.  It  has  been  shown 
that  sarcoma  of  bone  frequently  has  its  beginning  at  the  seat  of  an 
old  or  recent  fracture.  Arthritis  and  tendosyuovitis,  either  traumatic  or 
infective  in  origin,  are  to  be  classed  among  the  complications.  Short- 
ening of  the  limb  can  be  the  result  of  overriding,  of  impaction,  of  loss 
of  substance,  or  of  developmental  defect  following  the  separation  of 
an  epiphysis.  All  the  complications  of  wounds,  including  especially 
suppuration  and  tetanus,  are  among  the  complications  of  compound 
fractures.  Surgical  emphysema  results  from  the  entrance  of  air  or  gas 
into  the  connective-tissue  spaces.  It  is  usually  found  associated  with 
a  fracture  in  which  there  is  a  wound  of  the  lung,  or  of  some  part  of 
the  respiratory  tract,  or  in  the  region  which  shares  in  the  respiratory 
movements.  Air  thus  admitted  penetrates  the  loose  subcutaneous 
connective  tissue,  and  may  extend  over  a  large  area  of  the  body,  giving 
a  peculiar  crackling  and  crepitating  sensation  upon  pressure.  Certain 
gas-producing  micro-organisms  cause  a  similar  phenomenon  after  gain- 
ing access  to  a  wound. 

Hypostatic  congestion  of  the  lungs,  bed-sores,  inhibition  of  the 
function  of  the  excretory  organs,  suppression  of  urine,  retention  of 
urine,  are  complications  commonly  found  in  old  or  debilitated  persons. 
These  are  the  special  dangers  which  threaten  the  old,  and  render  con- 
finement in  bed  a  matter  of  great  hazard.  In  such  cases  every  effort 
should  be  made  to  carry  on  the  treatment  in  such  a  way  that  the 
patient  may  not  be  kept  constantly  in  the  dorsal-recumbent  position. 
It  is  much  better  surgery  to  be  satisfied  with  a  less  perfect  local  result, 
and  preserve  the  patient,  than  to  allow  technical  zeal  to  strive  for  a 
perfect  cure  of  the  fracture  at  the  cost  of  the  patient's  life. 

Delirium  tremens  is  prone  to  occur  in  persons  who  have  habitually 
taken  alcohol,  and  who  for  some  reason  are  compelled  to  remain  for  a 
considerable  length  of  time  in  the  recumbent  position.  Traumatic 
delirium  or  delirium  nervosum  is  a  condition  of  nervous  excitement  fol- 
lowing injuries  observed  in  neurotic  persons.  Crutch-paralysis  is  one 
of  the  later  complications.  It  arises  from  the  pressure  of  a  crutch 
upon  the  nerves  in  the  axilla,  producing  paralysis  of  the  muscles  of  the 
arm. 

Besides  the  immediate  and  mediate  complications,  there  are  certain 


FRACTURES.  $23 

later  complications  which  are  observed  after  the  fracture  has  united 
and  treatment  has  been  discontinued.  The  gradual  appearance  of 
deformity  at  the  seat  of  fracture,  resulting  from  instability  or  softening 
of  the  callus,  requires  reimmobilization  or  treatment  for  faulty  union. 
Persistent  atrophy  may  be  due  to  continued  disuse,  nerve-disease,  cir- 
culatory disturbance,  joint-ankylosis,  or  to  retarded  development  sub- 
sequent to  the  separation  of  an  epiphysis.  Neuralgia  sometimes  per- 
sists as  the  result  of  pressure  upon  a  sensory  nerve  or  infiltration  of 
the  nerve  with  new  connective  tissue. 

Faulty  or  vicious  union  results  from  the  absence  of  treatment  of 
fractures,  or  when  consolidation  has  been  allowed  to  take  place  with 
the  fragments  not  in  normal  apposition.  It  may  occur  associated  with 
any  of  the  forms  of  displacement.  The  usefulness  and  symmetry  of  a 
limb  may  thus  be  greatly  impaired,  and  symptoms  arising  from  press- 
ure upon  vessels  and  nerves  may  be  produced.  If  the  deformity  is 
near  a  joint,  the  function  of  the  joint  is  impaired.  If  the  deformity  is 
but  slight,  the  impairment  of  function  inconsiderable,  and  the  patient 
satisfied  with  the  result,  no  treatment  need  be  urged.  In  the  more 
extreme  cases  the  bone  should  be  refractured,  the  deformity  corrected, 
and  the  treatment  of  the  fracture  begun  anew.  Within  the  first  few 
weeks  the  refracture  of  a  bone  with  angular  deformity  is  a  simple 
matter;  but  when  the  fracture  is  old,  or  situated  near  a  joint,  or  has 
healed  with  overriding,  great  care  is  required.  The  bone  may  be 
broken  by  simple  manual  force ;  but  it  is  well  to  bind  splints  firmly  to 
the  limb  above  and  below  the  point  where  it  is  desired  to  make  the 
break,  in  order  to  localize  the  strain.  The  bone  should  be  broken  by 
a  quick,  strong  force,  rather  than  by  a  gradually  increasing  force.  The 
instrument  known  as  the  osteoclast  may  be  used  with  advantage  in 
some  cases.  The  most  exact  treatment  is  by  osteotomy.  This  may 
be  done  by  a  subcutaneous  operation  in  the  more  simple  cases,  or  by 
the  open  method  in  cases  with  overriding  of  the  fragments.  It 
often  becomes  necessary  to  resect  a  portion  of  the  bone  before  a  per- 
fect reposition  can  be  accomplished. 

Delayed  Union. — The  term  delayed  union  is  applied  to  those  cases 
in  which,  though  the  processes  which  bring  about  union  are  going  on, 
the  production  of  ossification  in  the  callus  is  slow.  It  is  a  retardation 
of  the  reparative  process,  whereby  the  bone  is  united  by  unossified  or 
imperfectly  ossified  connective  tissue  or  callus.  Imperfect  immobiliza- 
tion, too  early  mobilization,  overriding,  and  separation  of  the  fragments 
are  important  etiological  factors.  Local  inflammation  in  compound 
fractures  is  a  common  cause  of  delayed  union.  It  may  be  due  to 
certain  constitutional  disturbances,  such  as  the  slow  production  of 
plastic  material  at  the  seat  of  fracture  from  local  or  general  nutritive 
defects,  or  to  the  slow  ossification  of  the  callus  from  a  poverty  of  lime- 
salts. 

The  treatment  of  delayed  union  consists  first  in  removing  any  dis- 
coverable cause.  The  local  nourishment  should  be  improved  by  increas- 
ing the  blood-supply.  This  may  be  done  by  improving  the  patient's 
general  condition.  The  fracture  being  perfectly  immobilized,  the  patient 
should  be  encouraged  to  go  about  as  much  as  possible.  The  local 
blood-supply  may  be  increased  by  irritation.     This  is  accomplished  by 


524  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

hammering  the  region  of  the  fracture  each  day  with  a  padded  wooden 
hammer  or  with  a  hammer  of  paraffin  or  wax.  The  application  of  the 
electric  current  is  of  questionable  value.  Blistering  and  cauterization 
over  the  fracture  are  of  very  little  value.  Good  results  are  secured  by 
driving  into  the  bone-ends  pegs  of  bone,  which  are  allowed  to  remain 
in  situ.  The  bones  may  be  bored  or  punctured  in  several  places  with- 
out leaving  in  any  pegs.  A  most  valuable  means  of  arousing  hyperemic 
reaction  is  to  break  asunder  forcibly  the  fibrous  attachment  by  flexion 
and  rotation,  followed  by  rubbing  the  bone-ends  together.  This  should 
be  done  under  general  anesthesia.  If  necessary,  the  operation  should 
be  repeated  till  pain,  tenderness,  and  considerable  swelling  have  appeared. 
Another  plan  is  to  drive  the  bone-ends  forcibly  together  to  the  degree 
of  producing  impaction.  After  sufficient  irritation  has  been  produced 
by  these  measures,  the  limb  should  be  thoroughly  immobilized.  Six 
months  is  not  too  long  a  time  to  give  to  securing  consolidation. 

Fibrous  or  ligamentous  union  consists  in  the  connection  of  the 
bone-ends  by  means  of  unossified  fibrous  connective  tissue,  which  per- 
mits more  or  less  motion  between  the  fragments.  It  is  unremedied 
delayed  union,  and  may  be  due  to  any  of  the  causes  which  produce 
delayed  union.  The  interposition  of  soft  tissue,  such  as  muscle,  fascia, 
and  blood-clot,  between  the  fragments  is  one  of  the  most  prolific  causes 
of  this  accident.  When  the  treatment  for  delayed  union  has  been 
unsuccessful,  and  when  there  seems  to  be  no  tendency  to  ossification, 
or  if,  for  some  reason,  a  more  speedy  and  certain  cure  would  be  arrived 
at,  more  radical  operative  measures  are  justified.  The  bone  should  be 
cut  down  upon,  the  intervening  tissue  removed,  the  fragments  freshened 
by  sawing  off  the  ends,  and  the  freshened  bone-surfaces  brought 
together.  It  is  often  found  that  the  bone  near  the  fracture  has  become 
atrophied  and  porous.  When  this  condition  exists,  the  periosteum 
should  be  stripped  away  from  the  bone,  but  left  attached  to  the  sur- 
rounding tissue  ;  the  most  softened  part  of  the  degenerated  bone  should 
then  be  cut  away.  It  sometimes  occurs  that  there  is  so  great  a  destruc- 
tion of  bone  that  a  considerable  space  is  left.  It  may  be  necessary  to 
fill  this  by  an  osteoplastic  operation,  or  by  the  transplantation  of  bone. 
Finally,  there  are  cases  of  old  fibrous  union  in  which  the  very  slight 
motion  does  not  materially  impair  the  usefulness  of  the  limb.  These 
cases  need  no  treatment. 

The  constant  rubbing  together  of  the  fibrous  covered  ends  of  the 
bones  sometimes  results  in  the  formation  of  a  bursal  sac  between  the 
fragments.  Thus  a  new  joint  is  formed,  in  which  the  connective  tissue, 
representing  the  unossified  callus,  forms  the  capsular  ligament.  If 
operative  treatment  is  indicated,  the  new  joint-sac  must  be  removed, 
and  the  treatment  proceeded  with  upon  the  lines  laid  down  above. 
Non=union  is  a  comparatively  rare  condition  in  which  little  or  no 
reparative  action  has  taken  place.  In  this,  the  bone-ends  are  found  not 
connected  by  any  new-formed  tissue  whatever,  but  lie  free  in  the  sur- 
rounding soft  structures  without  having  excited  any  reparative,  exuda- 
tive reaction.  It  may  be  due  to  the  causes  which  contribute  to  delayed 
union  and  fibrous  union,  but  is  more  dependent  upon  malnutrition. 
The  treatment  is  the  same  as  that  for  delayed  union,  followed,  if  neces- 
sary, by  the  treatment  which  is  applied  for  ligamentous  union. 


SPECIAL   FRACTURES.  525 

Intrauterine  fractures  are  of  surgical  importance  chiefly  from  the 
standpoint  of  vicious  union  and  developmental  defects.  They  are  due 
to  traumatisms  to  the  child-containing  uterus  and  to  uterine  contrac- 
tions. The  predisposing  causes  are  syphilis,  osteitis,  malnutrition,  and 
malformations. 

SPECIAL  FRACTURES. 

The  Nose. — The  projecting  bony  and  cartilaginous  framework  of 
the  nose  is  the  frequent  seat  of  fracture,  caused  by  the  direct  violence 
of  blows  received  by  it  or  of  falls  upon  it.  The  damage  sustained  may 
be  of  every  degree  of  severity,  from  simple  diastasis  and  deflection  of 
the  cartilaginous  septum,  or  fracture  of  the  thin  projecting  edge  of  a 
nasal  bone,  to  much  comminution  and  marked  depression  of  the  whole 
bony  arch,  with  fracture  of  the  perpendicular  and  cribriform  plates  of 
the  ethmoid.  While  the  more  serious  and  extensive  injuries  are  usually 
recognizable  on  sight  by  the  marked  deformities  which  they  produce, 
the  slighter  injuries  are  not  infrequently  overlooked,  being  masked  by 
swelling  of  the  overlying  soft  parts  ;  and  not  till  after  this  has  sub- 
sided is  it  appreciated  that  consolidation  of  malposed  fragments  has 
already  occurred,  with  permanent  deformity.  As  early  as  possible, 
therefore,  careful  examination  should  always  be  made  of  the  whole 
framework  of  a  nose  which  has  been  subjected  to  violence,  to  detect 
and  remedy  any  displacement  that  may  be  present,  since  even  slight 
deviations  from  its  normal  contour  or  direction  inevitably  produce 
notable  permanent  disfigurement,  and  unrelieved  deviations  of  the 
septum  not  only  entail  deformity  of  the  nose,  but  may  lead  to  subse- 
quent chronic  disease  of  the  nasal  passages  by  reason  of  the  inter- 
ference which  they  produce  with  the  freedom  of  the  respiratory  current 
through  the  side  toward  which  they  project. 

The  triangular  cartilage  of  the  septum  may  be  torn  from  its  bony 
attachments  either  posteriorly  or  inferiorly,  or  the  extent  of  the  dias- 
tasis may  involve  both  lines  of  attachment.  Such  an  injury  results 
from  blows  upon  the  anterior  portion  of  the  nose,  more  especially  in 
children.  A  lateral  cartilage  may  be  torn  away  from  its  attachment 
to  the  edge  of  the  nasal  bone,  with  or  without  injury  to  the  septum. 
Deprived  of  its  natural  support,  such  a  cartilage  tends  to  fall  inward, 
making  the  lower  edge  of  the  nasal  bone  to  appear  as  a  lateral 
prominence. 

The  fracture  of  the  nasal  bone  may  be  a  minor  incident  in  a  more  extensive  injury 
involving  the  bones  of  the  face  and  orbits.  If  the  nasal  process  of  a  superior  maxillary 
bone  is  involved,  rupture  and  obstruction  of  the  lacrimal  duct  are  possible  complications. 
In  one  case  which  came  under  my  observation,  the  entire  bony  framework  of  the  face  and 
of  the  orbit  on  the  left  side  was  crushed  by  a  mass  of  iron  chain  which  fell  upon  it,  tearing 
away  the  left  eye  and  cheek.  Both  nasal  bones  were  fractured.  In  another  case,  by  the 
kick  of  a  horse  the  bones  of  the  face  were  separated  from  the  cranium  by  an  open  line  of 
fracture  through  the  superior  maxillary,  nasal,  and  ethmoid  bones.  Even  in  these  cases  of 
extensive  and  multiple  injuries  it  is  important  that  the  condition  of  the  nasal  bones  be 
appreciated  and  the  best  possible  position  for  them  secured,  so  that  the  ultimate  deformity 
may  be  as  slight  as  possible,  for  recovery  from  very  extensive  crushing  injuries  of  the  face  is 
not  infrequent. 

By  far  the  most  frequent  seat  of  fracture  of  the  nasal  bones  proper 
is  at  some  point  along  their  lower  half,  where  they  are  thinnest,  least 
supported  by  other  bones,  and  most  exposed  to  violence  (Fig.  220). 


526 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


According  to  the  location  of  the  fracture  and  the  direction  of  the 
injuring  force,  there  may  be — first,  a  deviation  of  the  fragments  to  one 
side,  with  or  without  special  depression  ;  or  second,  a  sinking  in  of  the 
bridge  of  the  nose  with  an  uptilting  of  the  tip  ;  or  third,  a  flattening 
and  depression  of  the  tip  with  broadening  of  the  base.  Depression 
of  the  bridge   or  tip  necessarily  involves  fracture  or  displacement  of 


Fig.  220. — Fracture  of  the  nasal  bones  (Hoffa). 


the  septum.  Comminution  of  the  fragments  is  frequent,  and  so  also  is 
laceration  of  the  cutaneous  or  mucous  covering,  exposing  the  line  of 
fracture. 

Treatment. — The  reposition  in  their  normal  position  of  displaced 
fragments  of  the  septum  and  bony  arch  of  the  nose  is  to  be  accom- 
plished by  careful  manipulation  by  the  fingers  applied  externally,  aided, 
if  necessary,  by  the  insertion  of  suitable  levers  and  forceps  into  the 
nasal  cavities,  whereby  depressed  fragments  ma)'  be  lifted  up  and 
deflected  parts  straightened.  Any  lever  intended  to  press  up  a  nasal 
bone  must  be  quite  thin,  not  more  than  \  inch  in  thickness,  on  account 
of  the  narrow  space  between  the  bone  and  the  septum.  Such  a  lever, 
of  suitable  thickness  and  length,  may  usually  be  readily  extemporized 
with  a  pocket-knife  out  of  a  slip  of  wood.  A  pocket-case  director  or 
even  a  hairpin  may  prove  serviceable. 

Not  infrequently  such  impaction  of  the  displaced  fragment  will  exist 
as  can  be  overcome  only  by  the  use  of  considerable  force.  When 
ordinary  means  fail  to  reduce  such  an  impaction,  it  would  be  justifiable 
to  drive  a  narrow  chisel  through  the  skin  from  without  underneath  the 
fragment  and  pry  it  up  into  place.  It  may  be  necessary  to  place  the 
patient  under  the  influence  of  a  general  anesthetic  to  secure  tolerance 
of  the  necessary  manipulations.  No  hesitation  should  be  felt  in  resort- 
ing to  such  anesthesia  whenever  required  to  facilitate  adequate  exam- 
ination and  proper  adjustment. 

Whatever  displacement  or  deflection  of  the  septum  exists  may  best 
be  remedied  by  the  use  of  forceps  with  flat  parallel  blades,  by  which 
the  septum  is  seized  and  forcibly  replaced.     Recurrence  of  the  deflec- 


SPECIAL   FRACTURES.  S27 

tion  may  be  prevented  by  a  tampon  in  the  nasal  passage  toward  which 
the  displacement  tends  to  occur,  or  by  fixing  the  septum  in  place  by 
pins  thrust  through  it  from  above  downward  or  from  before  backward, 
in  such  a  manner  as  to  control  the  movable  lacerated  part  and  hold  it 
in  the  required  position  until  healing  has  become  well  advanced. 

This  use  of  fixation-pins  is  preferable  to  the  use  of  intranasal  tam- 
pons, since  the  respiration  is  not  obstructed,  and  opportunities  of 
inspection  and  irrigation  of  the  parts  are  freely  afforded.  The  pins 
used  may  be  the  ordinary  steel  toilet-pins  with  glass  heads.  The  point 
may  be  thrust  through  the  anterior  part  of  the  septum,  just  within  the 
nostril,  and  carried  backward  to  be  buried  deeply  in  the  portion  beyond 
the  line  of  fracture  ;  or  it  may  be  introduced  through  the  outer  wall 
of  the  nose,  and  carried  downward  by  the  side  of  the  replaced  septum 
until  it  has  become  firmly  engaged  in  the  intermaxillary  suture. 

When  both  nasal  bones  are  comminuted,  and  especially  when  the 
nasal  processes  of  the  superior  maxillary  bones  are  also  fractured,  the 
fragments  may  best  be  kept  in  place  by  the  device,  suggested  by 
Mason,  of  passing  a  pin  transversely  through  the  nose  under  the  frag- 
ments, entering  it  in  the  line  of  fracture  in  the  nasal  processes.  A  pin 
so  placed  gives  reliable  and  constant  posterior  support  to  the  fragments. 
Lateral  compression,  if  needed,  can  be  obtained  by  stretching  a  ribbon 
of  rubber  tissue  \  inch  wide  over  the  bridge  of  the  nose,  either  end  of 
the  ribbon  being  punctured  and  secured  by  an  end  of  the  pin.  Should 
the  line  of  fracture  not  be  sufficiently  symmetrical  on  the  two  sides  of 
the  nose  to  permit  the  passage  of  the  pin  in  the  desired  line,  the 
unbroken  bone  should  be  pierced  with  a  drill  at  the  desired  level,  so 
as  to  permit  the  pin  to  be  carried  through  it.  At  the  end  of  a  week 
consolidation  will  be  sufficiently  advanced  to  insure  the  retention  of 
the  fragments  in  their  proper  position  without  the  aid  of  the  pin,  so 
that  it  may  then  be  withdrawn. 

In  the  primary  dressing  of  a  compound  comminuted  fracture  of  the 
nasal  bones,  no  fragment  of  bone  should  be  removed  unless  it  is 
entirely  detached  from  the  soft  parts  and  lies  loose  in  the  wound,  since 
an\'  loss  of  substance  in  the  framework  of  the  nose  entails  noticeable 
deformity. 

In  occasional  instances  some  emphysema  of  the  eyelids  and  face 
results  from  air  forced  into  the  superficial  tissues  in  efforts  at  blowing 
the  nose.  It  calls  for  no  treatment,  for  it  will  subside  spontaneously 
within  a  few  days. 

Malar  and  Superior  Maxillary  Bones. — Fractures  of  the  nasal 
process  of  the  superior  maxillary  bone  have  been  mentioned  in  con- 
nection with  fractures  of  the  nose.  More  or  less  of  the  alveolar 
process,  especially  in  front,  may  be  broken  off  by  blows  the  brunt  of 
which  has  fallen  upon  the  mouth.  The  cheek-bones  generally  both 
share  in  the  result  of  any  violence  severe  enough  to  produce  a  fracture 
in  either,  although  it  is  possible  for  the  orbital  or  zygomatic  process  of 
a  malar  bone  to  be  alone  fractured  by  the  direct  blow  of  a  narrow 
body.  In  the  more  common,  broadly  extended  blows  that  are  received 
upon  the  cheek,  the  malar  bone  together  with  the  prominent  malar 
process  of  the  superior  maxillary  bone  receives  the  chief  impact ;  and 
if  the  force  is  a  crushing  one,  according  to  the  direction  of  the  blow  the 


528  INTERNATIONAL    TEXT- BOOK   OF  SURGERY. 

malar  process  is  broken  across  and  with  the  malar  bone  is  displaced 
backward  into  the  zygomatic  fossa,  or  the  malar  is  driven  inward  into 
the  cavity  of  the  antrum  or  upward  into  the  floor  of  the  orbit.  Exten- 
sive laceration  of  the  overlying  soft  parts  and  much  comminution  of 
bone  often  complicate  such  fractures.  The  flattening  of  the  cheek 
which  results  when  the  cheek-bone  has  been  driven  backward  or 
inward  is  a  deformity  that  is  at  once  recognized  by  both  sight  and  touch  ; 
it  declares  plainly  the  nature  of  the  injury.  Further  irregularities  of 
bony  outline  may  also  possibly  be  felt  by  the  finger  applied  to  the  mar- 
gin of  the  orbit  or  to  the  outer  and  posterior  surface  of  the  bones 
accessible  from  the  buccal  cavity.  Mobility  and  crepitus  may  also  be 
elicited  whenever  the  fragments  are  not  immobilized  by  impaction. 
Injuries  to  the  lachrimal  canal  or  to  the  infra-orbital  nerve,  when  present, 
will  declare  themselves  by  the  special  symptoms  caused  by  interference 
with  their  functions.  Protrusion  of  the  eyeball  may  result  from  the 
encroachment  upon  the  orbit  of  the  displaced  fragment  or  from  hemor- 
rhage into  the  cavity  behind  the  ball.  In  cases  of  backward  displace- 
ment into  the  zygomatic  fossa,  the  movements  of  the  lower  jaw  may 
be  restricted. 

The  character  of  the  treatment  to  be  adopted  will  depend  upon  the 
extent  and  nature  of  the  displacement.  In  cases  in  which  the  displace- 
ment is  slight  and  the  deformity  of  but  little  moment,  if  the  fragment  is 
loose,  it  may  be  restored  to  its  place  by  pressure  of  a  finger  passed 
under  it  through  the  mouth  ;  if  it  is  too  firmly  fixed  by  impaction  to 
be  thus  moved,  the  fracture  may  be  disregarded  and  the  case  treated  as 
one  of  simple  contusion.  If  the  disfigurement  is  considerable,  and 
cannot  be  overcome  by  simple  manipulation,  an  incision  through  the 
skin  should  be  made,  sufficient  to  permit  a  blunt  hook  to  be  passed 
under  the  most  depressed  border  or  process,  by  means  of  which  it 
may  be  lifted  up  into  place ;  or  through  a  narrower  puncture  a  gimlet 
or  screw  may  be  driven  into  the  anterior  surface  of  the  depressed 
bone  and  used  to  lift  it  up ;  or  the  antrum  may  be  opened  from  the 
mouth  sufficiently  to  permit  the  introduction  of  a  metallic  instrument 
strong  enough  to  force  or  pry  up  into  position  the  depressed  fragment. 
In  open  fractures  the  wounds  of  the  overlying  soft  parts  give  ready 
access  for  such  procedures  to  the  fragments  beneath.  When  the  bones 
are  comminuted,  every  fragment  not  wholly  detached  should  be  pre- 
served with  care,  and  the  parts  moulded  back  into  as  good  shape  as 
possible.  Rapid  repair  is  the  rule  in  these  injuries,  and  the  ultimate 
disfigurement  is  often  far  less  than  could  at  first  have  been  expected, 
even  after  extensive  crushing  injuries,  provided  actual  loss  of  substance 
has  been  avoided. 

Retention  of  the  fragments  in  place  after  reposition  ordinarily  requires 
no  special  provision.  Any  tendency  of  a  fragment  to  drop  downward 
— a  tendency  more  likely  to  be  met  with  in  fractures  involving  the 
alveolar  process — can  be  controlled  by  using  the  lower  jaw  as  a  splint, 
the  lower  jaw  being  immobilized  by  the  head  and  chin  figure-of-8 
bandage.  The  upper  and  lower  dental  arcades  may  be  separated  by  a 
strip  of  gutta-percha  placed  on  either  side.  These  strips  should  be 
sufficiently  thick  to  separate  the  jaws  enough  to  permit  of  the  intro- 
duction between  the  teeth  of  liquid  food,  a  suitable  space  between  the 


SPECIAL    FRACTURES.  529 

strips  being  left  for  the  purpose.  The  gutta-percha  for  such  interdental 
splints  is  first  softened  by  immersion  in  hot  water,  and,  while  still  soft, 
is  put  in  place  so  that  it  shall  mould  itself  to  the  irregularities  of  the 
teeth  and  thus  provide  against  displacement. 

A  very  movable  and  depressed  malar  bone  was  supported  and 
retained  in  place  by  Abbe  by  means  of  a  drill  passed  through  the  solid 
part  of  the  zygoma.  The  drill  was  withdrawn  after  ten  days,  and  the 
bone  healed  without  deformity. 

The  I/Ower  Jaw. — The  exposed  position  of  the  lower  jaw  often 
causes  it  to  receive  violence  sufficient  to  fracture  it.  The  anterior  part 
of  the  body  of  the  bone,  between  the  mental  foramen  and  the  sym- 
physis, is  the  site  of  the  fracture  in  much  the  larger  proportion  of 
instances,  but  no  part  of  the  bone  is  free  from  the  possibility  of  fracture. 


Fig.  221. —  Fractured  lower  jaw.     Photograph  of  specimen  showing  most  frequent  location 
and  direction  of  fracture.     Internal  and  external  surfaces. 

Complete  fracture  at  two  or  more  points  distant  from  each  other 
is  not  infrequent.  Partial  fractures  involving  the  alveolar  border  are 
very  common  from  blows  upon  the  teeth  or  in  the  extraction  of 
teeth. 

In  complete  fractures  of  the  body  of  the  bone  the  line  of  fracture  is 
usually  transverse  to  the  long  axis,  and  with  but  little,  if  any,  antero- 
posterior obliquity,  except  in  fractures  in  the  posterior  half  of  the  body 
of  the  bone,  in  which  region  the  anterior  fragment  is  usually  longer  on 
its  inner  side,  and  the  posterior  fragment  on  its  outer  side. 

The  comminution  caused  by  gunshot  fractures  produces  multiple 
lines  of  fracture  that  are  not  susceptible  either  of  classification  or  of 
systematic  description. 

The  soft  parts,  both  externally  and  also  within  the  mouth,  are  fre- 
quently so  lacerated  as  to  render  the  fracture  a  compound  one.  Ordi- 
narily there  is  but  slight  displacement  of  the  fragments,  and  what  there 
is  may  be  readily  corrected  by  manipulation.  In  occasional  instances, 
as  the  direct  result  of  the  special  violence  which  has  caused  the  fract- 
ure, a  more  marked  degree  of  displacement  may  exist,  and  the  entan- 
glement of  a  tooth  or  a  bit  of  the  alveolar  process  between  the  frag- 
34 


53°  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

merits  or  the  interlocking  of  projecting  serrations  may  render  replace- 
ment in  apposition  more  difficult,  and  may  require  free  exposure  of  the 
line  of  fracture  by  suitable  incision,  in  order  to  detect  and  remedy  the 
cause  of  entanglement.  Fracture  at  the  neck  of  the  condyle  leaves 
the  condyloid  fragment  subject  to  the  unopposed  action  of  the  external 
pterygoid  muscle  by  which  it  is  drawn  upward  and  forward.  In 
double  fractures  of  the  body  of  the  bone  the  intermediate  piece  is 
drawn  downward  and  backward  by  the  unopposed  action  of  the  muscles 
of  the  neck  attached  to  it. 

Complete  laceration  of  the  inferior  dental  nerve  is  a  comparatively 
rare  complication,  the  more  common  location  of  fracture  being  in  front 
of  its  point  of  escape  from  the  dental  canal  at  the  mental  foramen,  and 
the  displacement  in  other  cases  being  rarely  great  enough  to  rupture 
the  nerve.  When  the  nerve  is  ruptured,  there  results  anesthesia  of  the 
lower  lip  and  chin  on  the  affected  side. 

The  diagnosis  of  fracture  of  the  lower  jaw  rarely  presents  any 
difficulties.  The  history  of  direct  violence  sustained  by  the  part  and 
local  impairment  of  function  with  swelling  and  tenderness  invite  exam- 
ination. Often  some  irregularity  of  outline  can  be  appreciated  at  once 
by  both  sight  and  touch,  and  by  manipulation  the  mobility  of  the  frag- 
ments and  crepitus  can  be  elicited,  and  the  exact  site  of  fracture  demon- 
strated. 

The  prognosis  is  good.  Failure  of  union  is  rare  even  in  cases  of 
comminution  with  some  loss  of  substance,  notwithstanding  the  frequent 
unavoidable  movements  between  the  fragments  in  swallowing  and 
speaking.  Nor  are  the  rapidity  and  certainty  of  repair  much  prejudiced 
by  the  lacerations  of  the  soft  parts,  which  expose  the  fracture  to  con- 
tact with  the  copious  secretions  of  the  mouth,  mingled  with  the  .secre- 
tions from  the  infected  wounds. 

Exfoliating  splinters  may  cause  abscesses,  but  necrosis,  except  of 
limited  portions  of  the  alveolar  border,  is  rare.  Deformity,  beyond 
possibly  a  slight  irregularity  of  the  teeth  not  sufficient  to  interfere 
with  mastication,  is  rare. 

Treatment. — Replacement  of  the  fragments  in  proper  position  in 
most  cases  is  readily  effected  by  slight  pressure  and  manipulation.  In 
the  exceptional  instances  in  which  difficulty  is  met  with,  the  cause  for 
it  must  be  sought  for  and  removed.  Loosened  teeth  at  the  point  of 
fracture  should  be  removed.  Obstinate  recurrence  of  displacement 
due  to  contraction  of  unopposed  muscles  calls  for  division  of  the  mus- 
cles at  fault.  Such  obstacles  to  ready  and  complete  reduction  and 
retention  having  been  removed,  retention  of  the  fragments  in  position 
may  usually  be  sufficiently  secured  by  bandaging  the  lower  jaw  to  the 
upper  by  a  simple  figure-of-8  chin-and-head  bandage,  applied  over  a 
chin-cup  formed  of  canton  flannel  or  towelling  saturated  with  plaster- 
of- Paris  cream.  To  form  this  cup  a  piece  of  canton  flannel  is  saturated 
in  thick  plaster-of- Paris  cream  and  folded  into  three  folds ;  the  folded 
piece  for  an  adult  should  be  from  6  to  8  inches  long  and  from  3  to  4 
inches  broad.  This  is  cut  along  the  middle  from  either  end  for  one- 
third  of  its  length,  the  middle  third  being  thus  left  uncut.  From  the 
center  of  either  edge  of  this  middle  portion  as  much  as  may  be 
required  for  the  lower  lip  and  for  the  throat  is  cut  away.     This  uncut 


SPECIAL    FRACTURES.  531 

portion  is  applied  to  the  chin,  which  it  will  cover  from  the  hyoid  bone 
to  the  furrow  below  the  lower  lip.  Then  the  two  lateral  tails  are 
pressed  upon  the  sides  of  the  jaw,  and  the  whole  secured  in  place  by 
the  figure-of-8  bandage.  When  the  plaster  has  hardened  the  cup 
should  be  removed  and  lined  with  a  thin  layer  of  cotton-wool  or  other 
soft  material.  It  is  then  reapplied  and  kept  in  place  by  the  bandage  as 
before.  Such  a  chin-cup  is  especially  indicated  to  prevent  displacement 
from  lateral  pressure  of  the  bandage  when  the  fracture  is  posterior  to 
the  mental  foramen  or  when  it  is  multiple.  When  the  fracture  is  an 
open  one  with  a  skin-wound,  suitable  fenestration  of  the  cup  and 
bandages  must  be  provided  to  facilitate  its  proper  care,  and  the  neces- 
sary absorbent  dressings  will  be  superadded  to  the  fixation-appli- 
ances. 

Careful  inspection  of  the  parts  should  be  made  as  found  to  be  neces- 
sary for  the  perfect  support  of  the  fragments  and  the  comfort  of  the 
patient.  Feeding  with  fluids  can  usually  be  satisfactorily  accomplished 
through  the  spaces  left  by  lost  teeth  or  the  natural  irregularities  of  the 
dental  arcades.  Cleanliness  of  the  mouth  may  be  secured  by  the  fre- 
quent use  of  antiseptic  mouth-washes  introduced  through  the  same 
channels. 

Repair  takes  place  rapidly,  so  that  by  the  third  week  the  con- 
stant use  of  the  retentive  apparatus  may  be  intermitted.  It  may  be 
abandoned  altogether  by  the  end  of  the  fourth  week,  but  not  until 
the  lapse  of  two  weeks  more  should  the  mastication  of  meat  be 
attempted. 

Should  it  be  found  impracticable  to  introduce  liquid  food  between 
the  closed  jaws,  or  should  the  absence  of  teeth  in  either  jaw  be  so 
extensive  as  to  prevent  the  proper  support  of  the  lower  jaw  by  the 
upper,  interdental  splints  may  be  used,  as  already  described  in  connec- 
tion with  fractures  of  the  upper  jaw.  In  the  absence  of  facilities  for 
making  interdental  splints,  feeding  may  still  be  satisfactorily  accom- 
plished as  long  as  necessary  through  a  tube  introduced  into  the  pharynx 
through  the  nasal  passages. 

Whenever  difficulty  is  found  in  maintaining  the  fragments  in  appo- 
sition by  the  means  already  described,  as  in  oblique  and  multiple  fract- 
ures or  in  compound  fractures  which  require  frequent  disturbance  of 
the  retentive  apparatus  for  dressings,  the  fragments  may  be  wired 
together  by  stout  silver  wire  passed  through  openings  made  by  a  drill 
through  the  whole  thickness  of  the  body  of  the  bone  from  before 
backward,  at  a  quarter-inch  or  more  distance  from  the  line  of  fracture 
on  either  side,  the  bone  having  first  been  pierced  by  a  suitable  drill. 
The  wires  may  be  removed  after  three  weeks. 

The  tying  together  of  the  fragments  by  stout  thread  or  silver  wire 
passed  around  sound  teeth  on  either  side  and  near  the  line  of  fracture 
has  often  been  resorted  to,  but  it  is  a  feeble  and  inefficient  device  in  the 
cases  which  require  special  support ;  even  firm  teeth  may  thereby  be 
speedily  loosened. 

Many  forms  of  elaborate  apparatus  have  been  devised,  combining 
vulcanized  interdental  splints  and  an  external  framework,  and  chin- 
plate  with  appropriate  nuts  and  screws  to  regulate  pressure,  secure 
adjustment,  and  hold  together  the  fragments  of  a  broken   lower  jaw 


532 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


until  consolidation  has  been  secured.  They  are  especially  indicated 
in  fractures  with  much  comminution,  as  in  some  gunshot  fractures. 
The  co-operation  of  a  dental  surgeon  is  essential  for  the  construction 
of  any  such  apparatus. 

The  mouth  is  thoroughly  washed  with  an  antiseptic  solution ; 
any  very  loose  teeth  arc  removed,  and  the  teeth  cleansed  from  tartar. 
An  impression  of  the  upper  jaw  is  then  taken  in  modelling  compo- 
sition, and  of  the  lower  or  fractured  jaw  in  modelling  composition 
or  plaster.  No  attempt  is  made  to  put  the  fragments  in  proper  posi- 
tion. 

Plaster  casts  are  made,  on  which  the  lines  of  fracture  are  clearly 
indicated  (Figs.  222,  223). 


FlG.  222. —  Plaster  cast  or  model,  there 
being  a  fracture  at  the  symphysis,  also  in 
the  region  of  the  third  molar,  which  is 
absent  (Moriarty). 


FlG.  223. — Model  of  same  jaw  after 
treatment.  The  left  central  tooth,  which 
was  loose,  was  extracted.  Observe  how 
perfectly  the  articulation  has  been  restored 

(Moriarty). 


With  a  fine  saw  the  cast  is  cut  on  these  lines,  and  the  plaster  cast  is 
articulated  with  the  cast  of  the  upper  jaw.  Plaster  is  run  around  to 
hold  the  severed  portions  in  position,  and  then  both  upper  and  lower 
casts  are  put  upon  an  articulator. 

The  process  of  making  an  aluminum,  gold,  or  vulcanite  splint  is 
familiar  to  every  dentist,  being  similar  to  that  of  making  an  ordinary 
plate. 

The  advantages  of  the  aluminum,  gold,  or  simple  vulcanite  splint 


FlG.  224. — Aluminum  or  gold  splint,  which  is  cemented  on  to  the  teeth. 


are  that  they  are  not  noticeable,  and  that  the  patient  can  use  the  mouth, 
being  able  to  open  and  close  it,  and  can  masticate  with  comfort. 


SPECIAL    FRACTURES.  533 

The  whole  course  of  treatment  of  fractures  of  the  lower  jaw  has 
been  systematized  by  dental  surgeons,  and  every  conceivable  variety  of 
fracfure    has  been   treated  by  methods 
which  are  fully  described  in  the  journals 
devoted  to  that  department  of  surgery. 

The  Hyoid  Bone. — Notwithstand- 
ing the  hyoid  bone,  by  reason  of  its 
mobility  and  its  retired  position  behind 
the  projecting  lower  jaw,  can  rarely  be 
exposed  to  fracturing  violence,  yet  the 
immunity  is  not  absolute.  Blows  upon 
the  neck,  or  falls  in  which  the  front  of 
the   neck   strikes    upon    the    projecting  FlG    225._Vuicanite   splin 

edge  of  an  object,  Or  circular    COmpreS-       boxes    vulcanized    on    each    side.     If 
r  ,i       c„„^„„  :.,  4.U ..^4-4-1  :^i«.  ^*-  s^C       the  jaw  is  fractured  in  the  region  of 

sion,  as  of  the  fingers  in  throttling  or  of     the  Jmolars   considerable  prefsure  is 

the  nOOSe  in  hanging,  have  been  the  required  to  get  the  parts  in  position ; 
USUal  Causes  of  the  accident.       Muscular       therefore  it  is  best  to  vulcanize  on  to 

the  sides  of  the  vulcanite  splint  boxes 
action     alone,     111      sudden      and     Violent       into  which  wire  arms  can  be  inserted. 

extension    of  the    neck,  is    claimed    to 

have  been  the  cause  in  some  instances.  In  the  recorded  cases  the 
usual  point  of  fracture  has  been  at  or  near  the  juncture  of  the  great 
cornu  with  the  body  of  the  bone.  In  a  considerable  proportion  of  the 
cases  (6  out  of  27,  Gurlt)  there  was  associated  with  it  fracture  of  the 
cartilages  of  the  larynx. 

The  symptoms,  in  addition  to  the  local  soreness,  tumefaction,  and 
ecchymosis,  arise  from  the  pain  which  is  caused  by  acts  involving  con- 
traction of  the  hyoid  muscles.  Swallowing  is  difficult  and  painful — for 
a  time  often  impossible.  Movements  of  the  lower  jaw  and  of  the 
tongue  awaken  pain.  The  fractured  cornu,  displaced  inward,  has  in 
some  cases  been  felt  by  palpation  with  a  finger  in  the  pharynx.  Crepi- 
tus cannot  usually  be  elicited.  When  the  larynx  is  also  injured,  the 
special  signs  of  that  injury  are  superadded,  such  as  dyspnea,  bloody 
expectoration,  and,  in  severe  cases,  emphysema. 

The  prognosis  depends  largely  upon  the  character  of  the  associated 
injuries,  which  are  often  fatal.  The  fracture  itself  is  usually  susceptible 
of  repair  by  bony  union,  but  cases  of  such  considerable  displacement 
as  to  cause  non-union  have  been  recorded.  Necrosis  of  the  fragment 
has  occurred. 

The  treatment,  after  any  manifest  displacement  has  been  corrected 
by  finger-pressure  from  within  the  pharynx,  is  necessarily  restricted 
simply  to  measures  to  immobilize  the  neck,  to  combat  the  local  inflam- 
matory reaction,  and  to  relieve  the  complications  arising  from  asso- 
ciated injuries.  The  dysphagia,  as  long  as  it  is  severe,  should  be  met 
by  rectal  feeding  or  by  the  use  of  an  esophageal  tube ;  dyspnea  from 
edema  of  the  glottis  may  call  for  intubation  or  tracheotomy.  Immo- 
bilization of  the  neck  may  be  secured  by  a  broad  posterior  collar  of 
plastic  material,  as  canton  flannel  saturated  with  plaster  of  Paris,  or  sole- 
leather  softened  by  hot  water,  the  collar  being  fastened  to  the  head  and 
shoulders  by  appropriate  bandaging. 

The  Sternum. — The  sternum,  by  the  sponginess  and  elasticity  of 
its  own  structure   and  the  elastic  support   which  is  given  it   by  the 


534  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

costal  cartilages,  is  so  protected  from  the  effects  of  violence  that  it 
rarely  becomes  fractured.  When  fracture  of  the  sternum  does  occur 
as  the  result  of  great  crushing  violence,  it  is  not  infrequently  associated 
with  such  other  severe  lesions — as  fractures  of  the  spine,  ribs,  or  skull, 
and  laceration  of  the  thoracic  viscera — as  to  render  of  little  importance 
the  sternal  injury.  While  the  more  frequent  cause  of  fracture  has 
been  a  direct  blow  or  crushing  force  received  by  the  bone,  in  a  con- 
siderable proportion  of  the  recorded  cases  the  fracture  has  been  caused 
by  forcible  and  extreme  bending  of  the  trunk,  either  backward  or  for- 
ward. In  a  number  of  instances  it  has  been  caused  by  the  violent 
muscular  struggles  of  difficult  parturition.  In  a  case  under  my  own 
care  it  was  caused  in  a  football  scrimmage. 

The  part  of  the  bone  most  frequently  fractured  has  been  that  por- 
tion of  the  body  lying  between  the  manubrium  and  the  point  of  articu- 
lation of  the  fourth  costal  cartilages.  Diastasis  at  the  junction  of  the 
manubrium  and  gladiolus  presents  no  practical  differences  from  a  fract- 
ure, and  does  not  require  separate  consideration. 

In  the  great  majority  of  instances  the  fracture  has  been  transverse 
in  its  general  direction,  though  cases  of  longitudinal  fracture  have  been 
observed.  The  amount  of  displacement  attending  the  fracture  will 
depend  upon  the  nature  of  the  violence  which  has  caused  it ;  usually 
it  is  not  great.  Some  projection  forward  of  the  upper  edge  of  the 
lower  fragment  is  usual,  recognizable  by  sight  and  touch.  Very 
marked  depression  of  the  upper  fragment  has  been  noted  in  some 
cases. 

In  addition  to  the  usual  signs  of  fracture  there  may  be  added  symp- 
toms of  internal  injury,  varying  according  to  the  extent  of  internal 
laceration  present,  including  dyspnea,  cough  with  bloody  expectora- 
tion, emphysema,  and  the  signs  of  hemothorax.  Infection  may  deter- 
mine, later,  widespread  mediastinal  suppuration.  The  prognosis  is 
favorable,  except  in  the  presence  of  serious  internal  injuries.  The 
fragments  unite  promptly  by  osseous  or  fibrous  union,  even  when  the 
displacement  is  marked  and  is  not  overcome. 

In  the  treatment  the  patient  should  first  be  placed  in  the  position 
in  which  he  finds  that  he  can  breathe  with  the  greatest  comfort.  This 
will  usually  be  in  a  half-sitting  position  with  a  firm  pillow  between  the 
shoulders.  This  position  will  at  the  same  time  tend  to  overcome  the 
displacement.  The  displacement  itself  does  not  call  for  persistent  and 
irksome  attempts  to  overcome  it,  unless  it  is  so  great  as  to  be  the  cause 
of  embarrassment  to  the  heart  or  lungs.  In  such  a  contingency  any 
operative  measure  required  to  elevate  the  fragments  would  be  justi- 
fiable. Otherwise  the  surgeon  should  content  himself  with  what  he 
can  secure  by  position  and  moderate  manipulation  and  pressure.  The 
thoracic  movements  should  be  restricted  by  encircling  the  thorax  with 
a  broad  band  of  adhesive  plaster.  Opium  may  be  given  for  the  double 
purpose  of  relieving  pain  and  diminishing  the  frequency  of  the  respi- 
rations. The  complications  of  intrathoracic  hemorrhage  and  of  medi- 
astinal suppuration,  the  first  as  an  immediate  and  the  second  as  a  later 
occurrence,  should  be  watched  for,  and  such  operative  measures  taken 
as  are  needed  to  expose  the  bleeding  point  or  drain  the  pus-focus. 

Ribs  and  Costal  Cartilages. — Fracture  of  the  ribs  is  a  com- 


SPECIAL   FRACTURES.  535 

paratively  common  accident.  In  my  own  experience  it  has  occurred 
about  one-half  as  frequently  as  have  fractures  of  the  femur,  62  patients 
suffering  from  fractured  ribs  and  131  from  fracture  of  the  femur  having 
been  admitted  into  the  Methodist  Episcopal  Hospital,  Brooklyn,  during 
the  period  1888  to  1900.  The  elasticity  of  the  thoracic  framework 
renders  children  less  liable  to  this  accident  than  adults,  but  it  is 
occasionally  observed  even  in  quite  young  children  ;  thus,  among  the 
cases  above  enumerated  there  was  one  child  of  three  years  who  had  six 
ribs  broken  by  the  kick  of  a  horse,  and  another  of  six  years  who  had 
three  ribs  broken,  having  been  run  over  by  a  wagon.  A  similar  cause 
produced  fracture  of  two  ribs  in  a  boy  of  thirteen. 

Violence  sufficient  to  cause  rib-fracture  may  act  either  by  staving  in 
the  rib  at  the  point  of  contact,  or  by  so  compressing  the  chest  as  to 
bend  the  rib  outward  until  it  gives  way  at  some  point  along  its  con- 
tinuity. The  former  is  the  usual  mechanism.  Out  of  25  cases  in 
which  I  have  preserved  a  record  of  the  nature  of  the  violence  done, 
9  resulted  from  falls  from  a  height,  7  were  sustained  in  railroad  acci- 
dents ;  in  4  instances  the  patient  had  been  run  over  by  a  wagon  ;  in  2 
a  crush  beneath  a  falling  body  had  occurred ;  in  2  the  patient  had  been 
kicked  or  knocked  down  by  a  horse ;  and  in  I  he  had  been  crushed 
between  the  rollers  of  machinery. 

Fracture  of  a  rib  has  been  alleged  to  have  been  caused  by  simple  violent  muscular  action, 
as  in  parturition,  and  even  in  sneezing.  It  is  reasonable  to  assume  that  a  pathological  fra- 
gility of  the  bone  must  have  pre-existed  to  contribute  to  the  production  of  a  fracture  from 
such  a  cause.  While  fracture  may  affect  any  part  of  a  rib,  any  rib,  and  any  number  of  ribs, 
the  more  sheltered  upper  two  ribs  and  the  more  movable  lower  ribs  are  less  frequently 
broken  than  the  central  group.  Fracture  by  direct  violence  occurs  with  great  frequency  in 
front  of  the  axillary  line  ;  fracture  by  indirect  violence  posterior  to  it,  near  to  the  angle  ; 
fracture  of  a  costal  cartilage  has  been  noted  more  frequently  near  the  costochondral  junction. 

Fracture  at  more  than  one  point  in  the  same  rib  occasionally  occurs,  and  fractures  of 
ribs  on  both  sides  are  not  rare.  Thus,  among  the  cases  mentioned  was  one  of  a  man,  sixty- 
five  years  of  age,  who,  after  falling  from  a  height,  was  found  to  have  sustained  double  fract- 
ures of  all   the  true  ribs  on  the  left  side  and  fracture  of  four  ribs  on  the  right  side. 

The  amount  of  displacement  in  most  cases  is  insignificant,  owing  to  the  support  which 
the  adjacent  unbroken  ribs  give  to  the  broken  one  ;  but  when  several  ribs  are  broken,  so 
that  the  side  sinks  in,  overriding  and  marked  angular  deformity  may  occur.  Incomplete 
fracture  and  fracture  without  complete  laceration  of  the  periosteum  the  writer  believes  to  be 
not  very  rare,  in  view  of  the  clinical  symptoms  occasionally  observed,  but  he  has  not  been 
able  to  verify  this  opinion  by  autopsy. 

Coincident  injuries  of  thoracic  or  abdominal  viscera,  or  of  other  portions  of  the  body, 
frequently  complicate  fractures  of  the  ribs,  being  the  natural  result  of  the  kind  of  violence 
to  which  rib-fracture  is  most  frequently  due.  These  complicating  injuries  are  important 
elements  in  both  prognosis  and  treatment.  Out  of  the  62  cases  already  referred  to,  19  died. 
Three  of  these  deaths  were  apparently  due  to  profuse  intrapleural  bleeding  from  lacerated 
intercostal  arteries  ;  2  were  due  to  lacerations  of  the  lung  and  to  the  consequent  intra- 
thoracic hemorrhage  and  traumatic  pulmonitis  ;  3  were  due  to  uremia  from  aggravation  of 
pre-existing  chronic  nephritis  ;  2  were  due  to  coincident  fracture  of  the  base  of  the  skull  and 
cerebral  laceration  ;  in  all  the  remaining  cases  there  were  ruptures  of  the  abdominal  viscera, 
usually  of  the  liver,  frequently  associated  with  multiple  contusions  and  fractures  in  other  parts 
of  the  body.  Laceration  of  the  pleura  is  the  necessary  consequence  of  any  notable  displace- 
ment of  the  fractured  rib-ends.  The  effect  of  this  is,  as  a  rule,  to  produce  only  a  circum- 
scribed adhesive  pleuritis,  but  in  occasional  instances  a  diffuse  suppurative  pleuritis  follows. 
It  is  but  rarely  that  any  considerable  bleeding  results  from  laceration  of  an  intercostal  artery  ; 
in  exceptional  instances,  however,  serious,  even  fatal,  hemorrhage  into  the  pleural  cavity  has 
been  due  to  this  source.  More  frequently  a  hemothorax  is  due  to  laceration  of  the  lung- 
tissue.  More  or  less  laceration  of  a  lung  is  a  common  result  of  a  crush  of  the  thorax  ;  this 
may  vary  in  degree  from  a  limited  contusion  of  the  lung-tissue,  with  a  variable  degree  of 
interstitial  ecchymosis,  to  extensive  tears  that  declare  themselves  at  once  by  hemoptysis,  of 
hemo-  and  pneumothorax,  and  emphysema,  while  bronchitis,  pneumonia,  or  gangrene  of  the 
lung  are  later  possible  sequela;.     Wounds  of  the  heart  and  great  vessels  have  been  recorded. 


536  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

The  symptoms  of  fracture  of  a  rib  consist  of  sharp,  circumscribed 
pain  at  the  injured  point,  which  is  aggravated  by  the  movements  of 
respiration  and  by  direct  pressure.  Moreover,  pressure  so  applied  as 
to  increase  the  arch  of  the  rib,  as  by  compression  made  upon  the 
sternum,  will  elicit  pain  at  the  injured  point.  Crepitus,  unnatural 
mobility,  and  deformity  may  be  observed  in  varying  degree.  These 
signs  will  be  most  easy  to  elicit  when  the  injury  is  seated  in  the  more 
superficial  portions  of  the  ribs,  or  when  several  ribs  are  broken.  The 
symptoms  and  results  of  complicating  laceration  of  the  lung  have  been 
already  briefly  stated.  In  this  connection  it  should  be  noted  that  the 
absence  of  the  spitting  of  blood  does  not  absolutely  contraindicate  the 
presence  of  lung-injury,  while  it  also  may  occur  in  the  absence  of 
laceration  of  the  lung-tissue. 

The  course  of  healing,  in  cases  unaccompanied  by  serious  visceral 
injury,  is  usually  quite  uneventful.  The  movements  of  respiration 
provoke  the  formation  of  an  abundant  ensheathing  callus,  and  rapid 
bony  repair  is  the  rule.  When  several  ribs  have  been  broken,  it  may 
happen  that  the  callus  is  abundant  enough  to  determine  the  formation 
of  lateral  bony  bridges,  welding  them  all  together.  In  the  complicated 
cases,  the  course  will  be  modified  by  the  nature  of  the  other  injuries, 
in  the  presence  of  which  the  rib-injury  becomes  of  but  little  moment. 
The  spitting  of  blood,  provoked  by  laceration  of  the  lung,  in  the  event 
of  the  injury  not  being  severe  enough  to  prove  speedily  fatal,  generally 
ceases,  in  great  measure,  in  the  course  of  forty-eight  hours,  giving  way 
to  rusty  sputa.  Emphysema  is  a  comparatively  rare  complication,  and 
when  it  does  occur,  even  though  the  extent  of  diffusion  may  be  wide, 
it  may  be  relied  on,  as  a  rule,  to  subside  speedily  and  spontaneously. 
In  the  event  of  serious  embarrassment  from  its  extent  and  persistence, 
free  incision,  sufficient  to  ensure  the  ready  external  escape  of  the  air 
pumped  out  from  the  lungs,  will  cut  it  short.  Air  within  the  pleural 
cavity,  entering  through  a  laceration  of  the  lung,  becomes  a  source  of 
danger  only  when  it  has  accumulated  under  pressure  until  it  begins  to 
compress  the  sound  lung  also.  The  establishment  of  an  external  vent 
suffices  to  relieve  the  special  danger. 

Bloody  effusion  into  the  pleural  cavity  becomes  a  complication 
requiring  special  attention  in  the  rare  instances  in  which  its  amount  is 
so  great  as  to  compromise  life  by  inducing  acute  anemia,  and  by 
attendant  pressure-dyspnea.  An  effusion  whose  amount  is  not  suf- 
ficient of  itself  to  produce  threatening  symptoms  may,  by  infection,  give 
rise  to  a  later  empyema,  with  its  special  symptoms  and  indications  for 
treatment.  Copious  intrapleural  bleeding  comes  in  most  instances  from 
lung-lacerations,  only  rarely  from  lacerated  intercostal  or  mammary 
arteries.  Cases  of  lesion  of  the  heart  or  great  vessels,  quickly  induc- 
ing death,  have  been  recorded.  The  usual  signs  of  progressive  acute 
anemia,  with  urgent  dyspnea,  and  the  physical  signs  of  fluid  in  the 
pleural  cavity,  supervening  upon  the  reception  of  a  blow  upon  the 
thorax,  are  sufficient  to  indicate  the  nature  of  the  complication.  The 
diagnosis  may  be  corroborated  by  the  use  of  an  aspirator  needle  and 
syringe.  While  serious  hemothorax  is  a  more  frequent  occurrence 
after  compound  fractures  and  penetrating  wounds  of  the  chest,  with  or 
without  fracture,  yet  it  is  an  occasional  complication  of  simple  fracture, 


SPECIAL   FRACTURES.  537 

and  cannot  be  ignored  in  connection  therewith.  The  spontaneous 
recoveries  from  extreme  hemothorax,  which  are  from  time  to  time 
reported  in  surgical  literature,  ought  not  to  be  accepted  as  warranting 
any  departure,  in  dealing  with  intrathoracic  bleeding,  from  the  principles 
of  hemostasis  established  for  other  parts  of  the  body — viz.,  to  expose 
the  bleeding  vessel  and  to  occlude  it  by  ligature,  compression,  or  cau- 
terization, as  the  conditions  of  the  particular  case  may  indicate.  The 
development  of  the  symptoms  of  serious  intrathoracic  bleeding  after 
rib-fracture  will  justify  the  surgeon  in  converting  the  simple  into  an 
open  fracture  by  incision,  and  the  raising  of  such  a  flap  of  the  chest- 
wall,  by  double  section  of  one  or  more  ribs,  as  will  secure  the  exposure 
of  the  bleeding  point  and  render  possible  the  necessary  procedures  fol- 
ks closure. 

The  treatment  of  the  fracture  itself  is  simple.  Any  displacement 
that  may  not  be  spontaneously  reduced  may  be  corrected  by  suitable 
pressure.  In  the  event  of  persistent  depression  which  causes  pain  or 
irritation,  the  depressed  fragments  may  be  drawn  outward  to  their 
proper  level  by  a  hook  introduced  underneath  them  through  a  punct- 
ure in  the  skin.  The  freedom  of  the  movements  of  the  chest-wall 
should  then  be  restricted  as  much  as  possible  by  encircling  the  thorax 
with  a  broad  strip  of  adhesive  plaster  6  inches  in  width.  This  should 
be  applied  during  forced  expiration.  Its  center  should,  as  a  rule,  pass 
over  the  site  of  fracture,  but  its  lower  border  should  not  come  lower 
than  the  ensiform  appendix,  lest  it  interfere  with  the  freedom  of  abdom- 
inal breathing.  The  frequency  of  the  respiratory  movements  may  be 
lessened  and  pain  may  be  controlled  by  full  doses  of  opium  during  the 
first  few  days  after  the  accident.  By  the  end  of  the  fourth  week  the 
special  bandage  may  be  dispensed  with. 

The  Clavicle. — By  reason  of  its  length,  its  slenderness,  and  its 
function  as  the  medium  through  which  the  root  of  the  upper  extremity 
is  articulated  with  the  trunk,  the  clavicle  is  often  the  subject  of  fract- 
uring violence,  particularly  in  young  children,  although  no  age  is 
exempt. 

The  most  common  cause  of  the  fracture  is  a  fall  upon  the  hand  or 
elbow,  or  upon  the  projecting  tuberosities  of  the  humerus  at  the 
shoulder.  The  force  in  such  cases  is  transmitted  through  the  glenoid 
cavity  of  the  scapula  and  the  coracoclavicular  ligaments,  and  finally 
culminates  as  a  twisting  strain  upon  that  portion  of  the  bone  which 
lies  internal  to  the  attachment  of  the  coracoclavicular  ligament  and 
external  to  that  of  the  costoclavicular  ligament.  As  a  matter  of  fact, 
by  far  the  great  majority  of  the  fractures  of  the  clavicle  have  their  seat 
in  the  outer  half  of  the  middle  third  of  the  bone.  When  the  force  is 
received  from  behind,  as  by  falls  upon  the  outer  and  back  part  of  the 
shoulder,  the  acromion,  violently  driven  forward,  carries  with  it  the 
acromial  end  of  the  clavicle.  When  the  free  forward  movement  of 
this  portion  of  the  bone  is  arrested  by  its  muscular  and  ligamentous 
attachment  to  the  trunk,  a  crossbreaking  strain  is  created,  and  more  or 
less  of  the  acromial  end  of  the  clavicle  may  be  torn  off.  A  fall  upon 
the  top  of  the  shoulder,  or  a  blow  received  at  that  point  from  a  falling 
body,  may  also  by  direct  force  fracture  the  acromial  end  of  the  clavicle. 
Fracture  of  the  outer  end  of  the  clavicle  is  much  less  frequent  than 


53S 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


fracture  of  the  middle  third  of  the  bone,  being  in  the  proportion, 
according  to  Gordon,  of  about  I  :  4.  Fractures  near  the  sternal  end 
of  the  bone  are  of  very  rare  occurrence.     To  cause  indirect  fracture  at 


Ext.  jugular  vein 

M.  trapezius. 
Clavicular  fascia  of  sternot  leidomastoid. 

External  extremity  of 
internal  fragment. 

Internal  extremity  of 

external  fray  men/. 


Deltoid. 


Cephalic  vein. 
Pectoralis  major. 


FlG.  226. — Fracture  of  the  middle  portion  of  the  clavicle  (Anger). 

this  point,  it  must  be  presupposed  that  a  crushing  force  has  been  sus- 
tained upon  the  outside  of  the  shoulder,  which  is  transmitted  directly 
in  the  longitudinal  axis  of  the  bone  to  its  fixed  sternal  end.     More 


1 

111 

V 

L 

Fig.  227. — Fracture  of  sternal  end  of  clavicle  ;  inferior  and  anterior  aspects. 

frequently,  in  this  contingency,  the  ligaments  give  way,  and  a  dislocation 
of  the  sternal  end  of  the  clavicle  results.  In  rare  instances  the  bony 
tissue  is  disrupted,  and  a  fracture,  with  some  impaction  and  comminu- 


SPECIAL   FRACTURES.  539 

tion,  is  produced.  Fig.  227  represents  a  specimen  taken  from  a  patient 
of  the  author.  The  man  fell  from  a  rapidly  moving  railroad  car  and 
struck  upon  his  right  shoulder,  crushing  the  head  of  the  humerus  and 
the  sternal  end  of  the  clavicle  upon  that  side,  as  shown  in  the  illustra- 
tion. 

The  clavicle  may  be  fractured  at  any  part  of  its  course  by  direct  blows,  but  fracture  from 
such  cause  is  not  common.  For  this  reason,  comminuted  and  compound  fractures  are  rarelv 
met  with,  and  leaving  gunshot  fractures  out  of  consideration,  injuries  to  the  blood-vessels 
and  nerves  at  the  root  of  the  neck  are  exceedingly  rare  as  complications  of  fracture  of  the 
clavicle.  On  the  other  hand,  the  special  mechanism  of  the  indirect  fracture  often  causes  the 
break  to  be  incomplete,  especially  when  the  spongy  and  elastic  clavicle  of  a  child  is  involved. 
Many  cases  have  been  recorded  in  which  the  clavicle  has  been  broken  by  violent  muscular 
contractions  alone,  as  in  an  attempt  to  lift  a  heavy  weight,  or  to  make  a  strenuous  effort  with 
the  attached  upper  extremity,  as  in  an  instance  under  the  observation  of  the  writer,  in  which 
a  young  woman,  who  was  bathing  in  the  surf  at  the  seashore,  was  violently  lifted  and  swept 
from  her  feet  by  an  incoming  roller.  While  striving  to  maintain  her  place  by  clinging  to  a 
fixed  rope  provided  for  the  purpose,  she  felt  something  give  way  in  her  neck,  and  afterward, 
upon  examination,  was  found  to  have  sustained  a  typical  fracture  of  the  middle  third  of  the 
clavicle. 

In  the  common  break  along  the  middle  third  of  the  bone  in  adults 
the  line  of  fracture  is  generally  oblique,  running  inward  and  downward 
or  backward ;  in  children,  transverse  fracture  is  not  uncommon. 
Variations  from  these  more  common  lines  are  not  infrequent. 

A  quite  uniform  displacement  so  often  follows  this  fracture  as  to  be 
characteristic  of  it.  The  end  of  the  outer  fragment  slips  behind  and 
below  the  inner  fragment,  so  that  the  end  of  the  inner  fragment  is  tilted 
upward  and  forward,  forming  a  notable  projection  at  the  base  of  the 
front  of  the  neck.  This  upward  tilting  may  be  increased  by  the 
contractions  of  the  sternocleidomastoid  muscle. 

The  primary  cause  of  this  displacement  is  the  continued  action  of  the  forces  which  break 
the  bone.  These  forces,  as  has  been  seen,  may  be  arrested  when  the  bone  is  only  partially 
fractured  ;  a  greater  force  results  in  a  complete  fracture  without  much  displacement ;  a  yet 
greater  force  tears  the  movable  broken  end  to  a  more  or  less  extent  from  its  fibrous  and  mus- 
cular attachments,  and  thrusts  it  backward  and  inward  behind  its  stationary  fellow.  The 
contraction  of  the  muscles  which  pass  from  the  thorax  to  the  clavicle,  scapula,  and  humerus 
tends  to  maintain  the  displacement.  The  scapula  glides  forward  and  somewhat  downward 
upon  the  convexity  of  the  thorax,  controlling  the  outer  fragment  of  the  clavicle,  which  is 
bound  to  it.  Conversely,  by  drawing  the  scapula  backward  the  attached  clavicle  fragment 
is  pulled  with  it,  and  usually  may  thus  readily  be  made  to  fall  into  proper  relation  with  the 
sternal  fragment. 

Fractures  of  the  clavicle  external  to  the  innermost  attachment  of  the  coracoclavicular 
ligament  often  display  a  marked  displacement  of  the  scapular  fragment  forward  and  inward, 
even  to  the  extent  of  forming  a  right  angle  with  the  sternal  fragment,  as  shown  in  the 
accompanying  illustration   (Fig.  228). 


FIG.  228. — Section  showing  the  relation  of  the  fragments  after  fracture  of  the  acromial  end  of 
the  clavicle,  healed  in  displacement  (R.  W.  Smith). 

Diagnosis. — The   symptoms   produced  by  fracture  of  the  clavicle 
vary  in  their  severity  according  to  the  extent  of  the  displacement  and 


54-0  INTERNATIONAL    TEXT- BOOK   OE  SURGERY. 

the  laceration  of  the  soft  parts.  Local  tenderness  upon  pressure,  more 
or  less  ecchymosis,  and  some  restriction  of  the  free  use  of  the  attached 
arm,  owing  to  pain  in  the  neck  caused  by  muscular  efforts,  may  be  all 
that  at  first  attend  the  less  severe  injuries,  in  which  the  break  is  incom- 
plete or  not  attended  with  displacement.  Within  a  few  days  the  devel- 
opment at  the  injured  point  of  an  easily  recognizable  mass  of  callus 
will  suffice  to  confirm  the  diagnosis.  In  the  more  common  fracture 
with  displacement,  inspection  of  the  neck  shows  at  a  glance  the  result- 
ing deformity  caused  by  the  projection  of  the  inner  fragments,  and  the 
position  of  the  fragments  and  their  unnatural  mobility  can  be  readily 
determined  by  the  touch.  A  posture  characteristic  of  the  accident  is 
involuntarily  assumed  by  the  patient  as  he  inclines  his  head  and  neck 
to  the  injured  side,  and  supports  the  elbow  and  forearm  by  the  hand 
from  the  sound  side.  When  the  displacement  is  reduced,  crepitus  may 
be  elicited.  The  amount  of  limitation  of  function  displayed  by  different 
individuals  with  practically  the  same  amount  of  local  injury  varies, 
depending  upon  the  sensitiveness  to  pain  which  the  individual  may 
possess.  The  movements  of  the  upper  extremity  can  be  made  as  freely 
after  the  accident  as  before,  and  whatever  limitation  seems  to  be  present 
is  a  voluntary  one  on  the  part  of  the  patient,  to  escape  pain.  Upon 
cursory  inspection,  fractures  near  either  end  of  the  bone  may  be  mis- 
taken for  dislocations,  but  care  in  examination  will  reveal  the  true 
nature  of  the  accident. 

Prognosis. — Rapid  repair  with  bony  union  usually  follows  this 
injury,  even  in  the  presence  of  marked  displacement  (see  Fig.  229). 
Firm  union  by  the  end  of  the  fourth  week  is  the  rule  in  adults.     Cases 

of  non-union  have  been  reported,  but 
in  these  cases  the  usefulness  of  the  arm 
has  been  very  little  impaired.  So  great 
are  the  practical  difficulties  in  over- 
coming the  tendency  to  displacement 
which  marks  the  usual  fracture,  that 
perfect  success  in  avoiding  deformity  is 
Fig.  229. — Healed  fracture  of  the     rarelv  obtained. 

clavicle,  united   in    extreme   deformity  _^  T      .,  cc 

(Gurlt)  Treatment. — In  the  cases  01  fracture 

without  displacement,  notably  in  the 
incomplete  fractures  of  children,  nothing  more  is  required  than  a 
simple  sling  to  support  the  forearm  and  a  broad  bandage  binding  the 
arm  to  the  thorax,  such  as  may  be  worn  with  comfort,  to  prevent  any 
such  free  use  of  the  arm  as  might  aggravate  the  local  injury.  If  the 
arm  is  not  inserted  into  the  sleeve  of  the  dress  or  coat,  but,  supported 
in  its  sling,  is  fastened  up  within  the  body  of  the  buttoned  or  pinned 
garment,  every  indication  will  be  satisfied. 

In  the  frequently  occurring  cases  with  displacement,  the  ingenuity 
of  the  surgeon  is  often  taxed  to  its  utmost  to  retain  the  fragments  in 
their  proper  position  sufficiently  to  secure  union  without  deformity ;  in 
a  very  large  proportion  of  cases,  despite  every  effort,  notable  deformity 
persists.  This  is  due  not  to  the  difficulties  in  bringing  the  fragments 
into  proper  relative  position,  but  to  the  fact  that  any  efficient  retentive 
bandage  or  apparatus  is  so  irksome  that  it  soon  becomes  intolerable. 
A  multitude  of  different  forms  of  apparatus  have  been  devised,  and  their 


SPECIAL    FRACTURES.  541 

description  burdens  the  pages  of  surgical  treatises  ;  the  fact  remains 
that  those  which  are  efficient  are  intolerable,  and  those  which  are  toler- 
able are  inefficient,  and  that,  as  a  rule,  the  good  results  which  are 
claimed  from  their  use  could  have  been  equally  well  secured  by  simpler 
means,  or  were  due  to  the  specially  favorable  nature  of  the  particular 
cases.  The  prime  indication  is  to  keep  the  scapula  pushed  well  back- 
ward around  the  convexity  of  the  thorax  toward  the  spine,  and  to  press 
its  posterior  border  closely  against  the  ribs.  The  acromion  is  thus  car- 
ried outward,  and  with  it  goes  the  outer  fragment  of  the  broken  clavicle. 
The  value  of  the  dorsal  decubitus,  unaided  by  apparatus  of  any  kind, 
to  secure  this  desired  fixation  of  the  scapula  is  well  established.  To 
secure  its  best  results  the  mattress  must  be  firm  and  even.  A  thin 
pillow  may  be  used  for  the  head  only,  so  as  to  relax  the  sternocleido- 
mastoid muscles.  The  elbow  should  be  kept  close  to  the  side,  while 
the  forearm  may  be  brought  over  upon  the  front  of  the  body  and  sup- 
ported there  by  a  suitable  sling.  After  about  two  weeks,  the  processes 
of  repair  will  be  so  far  advanced  as  to  enable  this  position  to  be  dis- 
pensed with,  without  much  danger  of  any  later  displacement  occurring. 
A  supporting  sling  and  a  restraining  bandage  should  be  worn  for  another 
two  weeks,  or  until  firm  consolidation  has  taken  place.  It  is  rare,  how- 
ever, that  the  mere  question  of  symmetrical  union  will  be  deemed  of 
enough  importance  by  a  patient  to  induce  him  to  undergo  the  irksome 
confinement  of  the  unremitted  dorsal  decubitus  for  the  required  length 
of  time. 

Of  the  various  devices  that  have  been  suggested  for  controlling  the 
scapula,  the  one  that  has  given  me  the  most  satisfaction  is  that  of  a  pair 
of  stuffed  collars  made  of  a  firm  roll  of  flannel  covered  with  muslin, 
one  encircling  snugly  each  arm  at  the  shoulder.  These  are  connected 
by  a  strap  of  bandage  across  the  back,  by  tightening  up  which  the 
scapulae  may  be  pulled  backward  toward  the  spine  with  force  and  held 
there  securely. 

A  moderate-sized  pad  is  next  fitted  in  the  axilla  of  the  injured  side, 
not  with  the  idea  of  any  use  as  a  fulcrum  over  which  to  exercise  lever- 
age with  the  arm  to  pry  the  shoulder  out — an  impracticable  notion — 
but  simply  to  afford  a  more  comfortable  support  for  the  arm  as  long  as 
it  is  to  be  confined  to  the  side.  This  pad  should  be  held  in  place  by  a 
sufficient  number  of  turns  of  a  roller  bandage  encircling  the  thorax. 
The  hand  is  now  placed  on  the  front  of  the  chest,  the  forearm  being 
flexed  at  an  acute  angle  with  the  arm,  which  latter  remains  at  the  side, 
falling  perpendicularly  from  the  shoulder.  Any  attempt  to  advance  the 
elbow  in  front  of  the  chest  or  to  carry  it  posteriorly  tends  to  shift  the 
acromion  forward,  and  is  therefore  to  be  avoided.  The  dressing  is.now 
completed  by  circular  turns  of  roller  bandage,  which,  beginning  at  the 
level  of  the  elbow,  bind  arm  and  forearm  securely  to  the  thorax. 
When  the  forearm  has  become  fully  covered  in  by  the  bandage,  the 
head  of  the  roller,  as  it  comes  across  the  back,  is  brought  around 
under  the  elbow,  and  thence  directly  upward  over  the  shoulder  of  the 
same  side,  and  down  again  behind  to  the  elbow.  From  three  to  four 
of  these  perpendicular  passes  should  be  made.  By  them  the  horizontal 
turns  are  reinforced  and  fixed  in  position.     Abundant  pins  are  finally 


542  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

introduced  at  points  where  the  turns  of  bandage  cross  each  other,  and 
the  dressing  is  completed. 

Frequent  inspection  and  readjustment  of  apparatus  is  especially 
necessary  in  the  treatment  of  fracture  of  the  clavicle.  By  the  fourth 
week  the  consolidation  is  usually  so  firm  that  special  apparatus  may 
be  discontinued  and  the  arm  entrusted  to  a  simple  sling,  which,  after 
another  fortnight,  may  be  cast  aside. 

Exposure  of  the  seat  of  fracture  by  incision,  replacement  of  the 
fragments  in  proper  position,  and  fastening  them  together  by  sutures 
or  dowel  pin,  may  become  necessary  in  those  rare  cases  in  which  either 
other  means  have  failed  to  overcome  the  tendency  to  displacement,  or 
it  is  especially  important  to  avoid  deformity,  or  the  symptoms  of  press- 
ure upon  blood-vessels  or  nerves  exist,  or  penetration  of  the  skin 
threatens  or  has  already  taken  place. 

The  Scapula. — Most  fractures  of  the  scapula  are  due  to  direct 
violence,  but  the  mobility  and  the  muscular  paddings  of  the  bone,  and 


Fig.  230. — Fracture  of  the  body  of  the  scapula  (Warren  Museum). 

the  elasticity  of  the  thorax,  against  which  it  rests,  cause  its  fracture 
from  any  cause  to  be  a  rare  occurrence.  The  processes  which  enter 
into  the  mechanism  of  the  shoulder  may  be  fractured  indirectly,  also, 
by  wolence  transmitted  through  the  humerus,  the  chipping  away  of 
more  or  less  of  the  rim  of  the  glenoid  cavity  (Fig.  232)  being  the  most 
frequent  of  the  indirect  injuries;  and  when  this  occurs,  it  is  usually 
associated  with  dislocation  of  the  head  of  the  humerus. 

Cases  have  been  reported  in  which  the  coracoid  process  was  torn 
off  by  muscular  contraction  alone.  The  acromion  process,  by  its 
prominence,  is  especially  exposed  to  vulnerating  influences,  and  its 
fracture  is  of  nearly  equal  frequency  with  that  of  the  body  of  the  bone. 
As  in  the  case  of  all  fractures  from  direct  violence,  such  injuries  of  the 
scapula  are  little  susceptible  of  systematic  classification  ;  any  portion 


SPECIAL    FRACTURES, 


543 


of  the  bone  may  be  fractured,  and  widely  varying  degrees  of  commi- 
nution and  of  injury  to  the  overlying  soft  parts  will  exist. 

Displacement  of  the  fragments  to  a  noticeable  extent  is  not  usual  in  the  injuries  of  the 
body  of  the  bone,  and,  when  present,  is  the  immediate  result  of  the  violence  sustained  rather 
than  of  muscular  contraction  ;  hence  it  is  not  apt  to  recur  after  replacement  by  suitable 
manipulation.  An  exception  to  this  statement  is  to  be  noted  when  a  small  portion  of  the 
posterior  edge  or  of  the  superior  angle  is  broken  off,  the  unopposed  action  of  the  rhomboids 
or  of  the  levator  anguli  scapulae  being  sufficient   to  cause  considerable  displacement  of  the 


Fig.  231. — Fractures  through  the  rim  of  the  glenoid  cavity  (Gurlt). 

fragments  to  which  they  may  be  attached.  When  the  acromion  is  broken  off,  the  deltoid 
tends  to  draw  the  fragment  downward  and  to  flatten  the  shoulder  ;  after  coracoid  fracture, 
displacement  may  be  limited  by  the  still  intact  coracoclavicular  ligaments.  Fractures  involv- 
ing the  glenoid  cavity,  including  fractures  of  the  neck  of  the  scapula  by  which  a  fragment, 
including  the  whole  articulating  cavity,  is  broken  off,  exhibit  the  most  marked  displacement, 
since  the  scapular  fragment  follows  the  head  of  the  humerus. 

The  diagnosis  will  be  based  on  the  presence  of  the  usual  signs  of 
fracture,  which  ordinarily  are  readily  apparent  upon  examination. 
Difficulty  may  attend  the  recognition  of  the  injuries  of  the  glenoid 
rim  and  of  the  neck  of  the  scapula,  on  account  of  the  resemblance 
which  its  conditions  present  to  that  of  dislocation  of  the  humerus, 
which  may  also  be  present  as  a  complication.  When  a  small  portion 
of  the  glenoid  rim  is  chipped  off  in  connection  with  a  dislocation,  it 
may  escape  recognition  altogether,  unless  in  the  manipulations  for 
reduction  crepitus  should  be  noticed.  The  absence  of  signs  of  a 
more  extensive  injury  of  the  scapula  or  of  the  humerus  would  indi- 
cate the  particular  lesion  that  had  occurred.  When  the  fragment  that 
has  been  split  off  involves  a  considerable  portion  of  the  glenoid  cavity, 
as  in  Fig.  231,  the  head  of  the  humerus  and  the  fragment  will  slip  away 
from  the  scapula  into  the  axilla,  the  condition  simulating  a  dislocation. 
The  displacement  is  easily  remedied  by  properly  applied  pressure,  but 
it  at  once  recurs  when  support  is  withdrawn  ;  crepitus  may  be  elicited 
during  the  manipulations.  The  same  symptoms  will  attend  a  fracture 
of  the  neck  of  the  scapula,  which  passes  posterior  to  the  base. of  the  cora- 
coid process,  if  the  coracoclavicular  ligaments  have  been  torn,  but  they 
may  be  distinguished  by  the  fact  that  in  the  latter  condition  the  cora- 
coid process  follows  the  movements  of  the  humerus,  while  in  the 
former  condition  it  moves  with  the  scapula.  The  contour  of  the 
shoulder  is  markedly  flattened  in  both  conditions,  and  by  this  fact 
they  are  differentiated  from  fractures  of  the  neck  of  the  humerus, 
which  are  not  attended  with  loss  of  the  normal  rotundity  of  the  part. 


544 


INTERNATIONAL    TEXT-BOOK   OE  SURGERY. 


Rapid  bony  repair  is  the  rule  in  fractures  of  the  scapula,  except 
when  the  acromion  or  the  coracoid  process  is  the  part  broken  off,  in 
which  cases  ligamentous   union  is  common. 

The  treatment  consists  in  the  adjustment  of  the  fragments  by 
manipulation,  followed  by  fixation  of  the  scapula  by  an  arm-and-body 
bandage.  In  general,  the  bandage  that  has  already  been  described  in 
connection  with  fractures  of  the  clavicle  will  be  most  suitable  for  fract- 
ures of  the  scapula  also,  the  shoulder-collars  being  omitted.  The  band- 
age of  Velpeau  will  also  answer  well,  except  in  cases  in  which  the 
posterior  border  is  torn  off. 

The  Humerus. — Fractures  of  the  humerus  naturally  group  them- 
selves, according  to  the  location  and  relations  of  the  part  of  the  bone 
injured,  into  fractures  at  the  shoulder,  fractures 
^-"  of  the  arm  proper,  and  fractures  at  the  elbow. 

Notable  differences  characterize  injuries  in  these 
three  regions  as  to  the  methods  of  their  pro- 
duction, their  course,  their  consequences,  and 
their  treatment. 

The  shoulder-injuries  comprise  all  the 
fractures  involving  the  part  of  the  bone  above 
the  insertion  of  the  axillary  muscles.  The 
head,  the  anatomical  neck,  the  two  tuberosities, 
and  the  surgical  neck  fall  within  this  limit,  and 
in  youth  the  irregular  epiphyseal  line  is  also 
included.  Fractures  of  this  portion  of  the 
humerus  result  from  falls  upon  the  shoulder 
or  impact  of  falling  bodies  against  it,  and, 
according  to  the  nature  and  direction  of  the 
crush,  the  extent  of  injury  may  vary  from  a 
longitudinal  fissure  of  limited  extent,  which 
during  life  may  be  indistinguishable  from  a 
mere  contusion,  to  a  comminution  of  the  whole 
upper  part  of  the  bone  by  multiple  radiating 
lines  of  fracture,  with  impaction  of  fragments  into  each  other  or  with 
marked  displacement.  Figs.  232  and  233  show  examples  of  the  more 
severe  forms  of  fractures  at  the  shoulder. 


FlG.  232. — Comminuted 
and  impacted  fracture  of  the 
head  of  the  humerus ;  head 
driven  downward  and  inward 
(Malgaigne). 


Fracture  through  the  surgical  neck  is  by  far  the  most  frequent  break  in  this 
region,  and  is,  with  reference  to  other  fractures  of  the  humerus,  a  relatively  common  acci- 
dent. Thus,  of  203  fractures  of  the  humerus  examined  by  Hamilton,  44  were  at  or  near  the 
surgical  neck,  6  were  supposed  to  be  epiphyseal  separations,  only  I  was  thought  to  be  a  fract- 
ure at  or  near  the  anatomical  neck,  with  impaction  and  splitting  of  the  tubercles,  and  1 
was  a  fracture  of  the  greater  tubercle  alone.  These  figures,  which  in  general  are  in  accord 
with  the  observations  of  others,  serve  to  show  both  the  frequency  of  breaks  through  the 
surgical  neck  and  the  rarity  of  recognizable  fractures  through  that  part  of  the  bone  above 
the  epiphyseal  line.  There  is,  however,  a  much  greater  proportion  of  cases  in  which  the 
head  of  the  humerus  has  been  severely  contused,  and  in  which  although  both  deformity  and 
crepitus  are  absent,  so  that  a  positive  diagnosis  of  fracture  cannot  be  made,  yet  the  persist- 
ence of  pain  and  muscular  rigidity  and  the  location  and  extent  of  the  ecchymosis  are  such 
as  lo  warrant  the  diagnosis  of  incomplete  fracture,  or  of  fissure,  or  of  fracture  in  which  the 
continuity  of  the  bone  is  maintained  by  untorn  periosteum,  with  or  without  slight  impaction. 
The  repair  of  these  fractures  is  so  complete  that  their  traces  are  too  slight  to  arrest  atten- 
tion when,  in  after  years,  the  subjects  come  to  the  dissecting  table,  and  thus  they  are  absent 
from  museum  shelves  and  do  not  enter  into  statistics.  Fig.  234  shows  a  case  in  point  of 
fracture  limited   to   the  tuberosities,  with  a   slight  degree  of  impaction,  which  might  have 


SPECIAL    FRACTURES. 


545 


escaped  recognition  during  life  had  not  the  fracture  been  associated  with  a  compound  dislo- 
cation of  the  head  of  the  humerus.      The  case  is  recorded  by  Bardenheuer.1 


FIG.  233. — Comminuted  fracture  of  the  head  of  the  humerus  ;  primary  line  of  fracture 
through  anatomical  neck,  secondary  splitting  away  of  the  great  tuberosity  (photograph  from 
specimen  in   Museum  of  the  M.  E.  Hospital,  Brooklyn). 


In  fractures  of  the  head  of  the  humerus  the  line  of  separation,  as  a 
rule,  runs  irregularly,  possibly  through  part  of  its  course  within  the 
capsule,  following  the  anatomical  neck, 
and  then  diverging  into  the  region  of  the 
tuberosities  (see  Fig.  233).  More  or  less 
splintering  of  the  expanded  upper  end  of 
the  shaft  is  common.  The  liability  to 
impaction  has  already  been  alluded  to. 
In  the  greater  number  of  cases  the 
fragments  are  not  entirely  separated, 
but,  in  addition  to  some  degree  of  im- 
paction, are  more  or  less  closely  held 
together  by  untorn  periosteum  and  the 
fibrous  tissue  of  the  capsule  and  tendon- 
sheath  that  invests  the  part. 

A  portion  of  either  tuberosity  is  oc- 
casionally torn  off  as  a  part  of  the  injury 
accompanying  a  dislocation,  the  greater 
tuberosity  being  the  part  most  frequently  injured.     A  similar  injury  to 

1  Die  Krankheiten  der  oberen  Extremitdten. 

35 


FlG.  234. — Impacted  fracture  of  the 
tuberosities  of  the  humerus  (Barden- 
heuer). 


54-6  INTERNATIONAL    TEXT-BOOK  OF  SURGERY 

a  tuberosity  has  resulted  from  violent  muscular  effort  alone.  In  fract- 
ures below  the  tuberosities  through  the  surgical  neck,  the  displacement 
is  also  often  incomplete,  owing  to  the  frequency  of  a  transverse  or  den- 
tated  line  of  fracture  and  the  thickness  of  the  fibrous  tissue  which 
invests  the  bone   here. 

When  complete  displacement  does  occur,  the  upper  end  of  the 
lower  fragment  is  commonly  drawn  forward  and  upward  toward  the 
coracoid  process,  where  it  forms  a  prominence  that  can  both  be  felt 
and  seen.  A  backward  displacement  may  result  from  the  special 
direction  of  the  force  to  which  the  fracture  may  have  been  due.  At 
any  age  up  to  the  twentieth  year  the  line  of  fracture  may  run  through 
the  epiphyseal  cartilage.  When  complete  disjunction  of  the  epiphysis 
is  produced,  the  upper  end  of  the  diaphysis  is  usually  displaced  for- 
ward, making  a  noticeable  projection  in  front  of  the  shoulder.  The 
upper  surface  of  this  projecting  bone  is  smoother  and  more  rounded 
than  the  irregular  or  dentated  end  of  the  lower  fragment  left  after  the 
common  fracture  of  the  surgical  neck.  The  condition  may  be  mistaken 
for  a  forward  dislocation  of  the  head  of  the  humerus,  until  more  full 
examination  shows  that  the  rotundity  of  the  shoulder  has  not  been  lost, 
and  that  the  head  of  the  humerus  is  still  present  in  the  glenoid  cavity. 
The  epiphyseal  fragment  may  be  rotated  by  the  muscles  which  are 
inserted  into  its  tuberosities,  until  its  under  concave  surface  looks  for- 
ward and  outward.  Efforts  to  bring  the  epiphysis  and  diaphysis  into 
their  normal  relations  are  liable  to  be  ineffectual,  owing  to  the  mobility 


*IG.  235. 

Figs.  235,  236. — Fracture  of  the  head  of  the  humerus  through  epiphyseal  line  (Whar- 
ton). Fig.  235  shows  the  relation  of  the  fragments  immediately  after  the  accident;  Fig.  236 
shows  the  condition  one  year  later :  consolidation  with  deformity  (skiagraphs  by  Goodspeed). 

of  the  epiphyseal  fragment  and  the  tendency  of  the  projecting  anterior 
edge  of  the  upper  end  of  the  diaphysis  to  become  entangled  in  the 
concavity  of  the  upper  fragment  (Figs.  235,  236). 

Diagnosis. — It  is  evident  from  the  statements  in  the  preceding  para- 
graphs that  in  many  cases  the  exact  differential  diagnosis  of  fractures 
of  the  upper  extremity  of  the  humerus  is  difficult  and  in  some  cases 


SPECIAL    FRACTURES.  $47 

impossible,  a  probable  or  approximate  diagnosis  being  the  most  to 
which  a  prudent  surgeon  should  commit  himself.  Fractures  without 
notable  displacement  and  fractures  with  impaction  give  symptoms  that 
are  not  to  be  positively  distinguished  from  those  of  contusion  without 
fracture,  as  long  as  the  surgeon  refrains  from  such  forcible  manipulations 
as,  by  breaking  up  impaction  and  rupturing  previously  untorn  periosteal 
and  fibrous  bands,  might  succeed  in  eliciting  crepitus  and  producing 
recognizable  displacement.  On  the  other  hand,  the  injunction  cannot 
be  made  too  emphatic  that  such  forcible  manipulations  for  the  purpose 
of  reaching  a  positive  diagnosis  should  never  be  resorted  to.  The 
swelling  of  the  overlying  soft  parts  may  be  such  as  to  obscure  signs 
that  might  otherwise  be  distinguishable.  In  the  examination  of  all 
shoulder-injuries,  all  clothing  should  be  removed  from  the  upper  part 
of  the  body,  so  as  to  permit  a  careful  inspection  of  the  injured  part  and 
its  comparison  with  the  sound  side  by  sight,  touch,  and  measurements. 
Dislocation  at  the  scapulohumeral  articulation  is  first  to  be  excluded  by 
determining  the  presence  of  the  head  of  the  humerus  in  the  glenoid 
cavity.  In  rare  instances  there  occur  simultaneous  dislocation  and 
fracture,  in  which  cases  examination  reveals  not  only  the  absence  of 
the  head  of  the  humerus  from  the  glenoid  cavity  and  its  presence  in 
an  abnormal  situation,  but  also  the  special  signs  of  fracture.  Swelling, 
tenderness  on  pressure,  pain  on  motion,  muscular  spasm,  and  ecchymo- 
sis  are  common  to  all  injuries;  but  when  they  occur  at  the  shoulder 
after  an  injury  to  the  head  of  the  humerus,  in  the  absence  of  disloca- 
tion, if  they  are  persistent  and  deep-seated,  and  especially  if  the  ecchy- 
mosis  is  extensive  and  is  effused  beneath  the  deeper  planes  of  tissue,  a 
probable  diagnosis  of  incomplete  fracture,  or  of  fracture  with  impac- 
tion, is  warrantable.  If  by  careful  manipulation,  combining  traction 
with  rotation,  crepitus  is  elicited,  the  diagnosis  is  made  positive.  When 
there  is  no  impaction  and  the  fracture  is  complete,  the  deformity  from 
displacement,  the  false  point  of  motion,  and  the  crepitus  may  combine 
to  declare  unmistakably  the  exact  nature  of  the  injury. 

The  prognosis  in  the  case  of  these  fractures  of  the  humerus  at  the 
shoulder,  so  far  as  union  of  the  fracture  is  concerned,  is  almost  invari- 
ably good.  In  the  cases  of  impaction,  consolidation  of  the  fragments 
in  their  new  relations  occurs  quickly ;  in  fracture  with  imperfectly 
reduced  displacement,  abundant  callus  forms  a  firm  bond  of  union  ; 
but  in  both  classes  the  irregular  position  of  the  fragments  and  the 
possible  formation  of  osteophyte  masses  may  limit  the  motions  of  the 
shoulder-joint,  and  even  in  the  absence  of  such  bony  obstacles  to  free 
motion,  intra-articular  fibrous  adhesion  and  thickening  and  contracture 
of  the  peri-articular  tissues  may  greatly  limit,  and  even  totally  destroy, 
the  function  of  the  joint.  Atrophy  of  the  shoulder-muscles  is  the 
rule,  and  in  some  cases  it  is  very  notable.  In  the  more  favorable  cases, 
the  stiffness  of  the  joint  and  the  muscular  atrophy  are  gradually  over- 
come, and  complete  disappearance  of  all  disability  results. 

Treatment. — Impacted  fractures,  incomplete  fractures,  and  fractures 
with  little  displacement  require  simply  that  the  parts  should  be  immob- 
ilized and  supported  by  a  broad  bandage  confining  the  injured  arm  to 
the  side  of  the  chest,  while  the  hand  and  wrist  are  supported  in  a  sling. 
Should  the  primary  swelling  and  pain  attending  the  injury  be  marked, 


54^  INTERNATIONAL    TEXTBOOK  OF  SURGERY. 

they  should  be  allayed  by  rest  in  bed,  and  the  application  for  a  few 
days  of  an  ice-bag  or  evaporating  lotions  to  the  shoulder.  After  the 
first  week,  the  muscles  of  the  shoulder  should  be  gently  massaged  daily, 
each  seance  continuing  from  fifteen  to  twenty  minutes,  for  the  purpose  of 
minimizing  muscular  atrophy  and  joint  stiffness.  At  the  beginning  of 
the  third  week,  careful  passive  motions  at  the  shoulder  may  be  begun, 
motion  being  never  forced,  but  only  carried  each  time  through  such  a 
range  as  provokes  neither  pain  nor  muscular  spasm.  At  the  end  of 
the  fourth  week,  the  restraining  body-bandage  should  be  discarded  and 
active  movements  begun. 

Fractures  zuit/i  displacement  at  the  surgical  neck  or  through  the 
epiphyseal  line  must  first  be  reduced  by  traction  and  manipulation. 
The  peculiar  entanglement  of  the  diaphysis  in  the  hollow  of  the  rotated 
epiphysis,  in  cases  of  epiphyseal  separation,  may  require  for  its  relief, 
as  has  been  pointed  out  by  Moore,  that  the  arm  should  be  carried 
upward  and  forward  to  the  perpendicular  line,  while  traction  and 
manipulation  are  made  to  bring  the  fragments  into  proper  apposition. 
The  arm  is  then  to  be  carefully  brought  down  to  the  side  of  the  body 
and  dressed  as  an  ordinary  fracture.  In  the  rare  instances  in  which  the 
fracture  is  complicated  with  dislocation  at  the  shoulder-joint,  the  dislo- 
cation must  first  be  reduced,  the  dislocated  fragment  being  exposed  by 
incision,  and  replaced  by  a  combination  of  pressure  and  traction  through 
hooks  and  forceps. 

For  the  further  protection  and  immobilization  of  the  fracture  a  splint 
composed  of  several  thicknesses  of  towelling  or  canton  flannel  saturated 
with  plaster  of  Paris  should  be  moulded  to  the  shoulder  and  outside 
of  the  arm,  down  to  the  condyle.  This  splint  should  be  made  to 
extend  well  over  the  top  of  the  shoulder  as  a  cap.  Between  the  inside 
of  the  arm  and  the  wall  of  the  thorax  should  be  placed  a  compress 
extending  up  into  the  axilla,  where  it  should  be  thickened  sufficiently 
to  fill  its  hollow,  but  not  enough  to  exert  any  tension  on  the  axillary 
muscles.  This  compress  should  be  fixed  in  position  by  adhesive  strips, 
or  a  turn  of  bandage  encircling  the  thorax ;  the  arm  with  its  external 
plastic  splint  should  then  be  secured  to  the  side  of  the  thorax  by  a 
sufficient  number  of  turns  of  a  broad  roller  bandage,  which  should  in 
its  application  begin  at  the  lower  part  of  the  humerus  and  gradually 
ascend,  until  it  has  reached  and  covered  in  the  shoulder.  No  attempt 
to  immobilize  the  elbow-joint  should  be  made,  and  the  anterior  half  of 
the  forearm  is  to  be  supported  by  a  sling,  so  that  the  natural  extension 
exerted  by  the  weight  of  that  portion  of  the  extremity  below  the  fract- 
ure may  not  be  interfered  with.  Such  readjustments  of  dressings  will 
be  made  from  time  to  time  as  may  be  required  for  the  comfort  of  the 
patient  and  the  continued  control  of  the  fracture.  Early  resort  to 
massage  is  not  so  important  as  in  the  fractures  of  the  head  of  the  bone, 
and  it  usually  should  be  deferred  until  the  third  week.  Passive  move- 
ments may  be  begun  at  the  end  of  the  fourth  week,  and  active  move- 
ments will  be  resumed  whenever  examination  shows  firm  consolidation 
to  have  taken  place. 

Fractures  of  the  shaft  of  the  humerus,  the  lower  limit  of  the  shaft 
being  considered  as  the  beginning  of  the  widening  and  flattening  of  the 
bone  about  2  inches  above  the  trochlear  surface,  may  present  in  differ- 


SPECIAL    FRACTURES.  549 

ent  cases  every  variety  of  break  and  every  form  of  displacement  that 
may  occur  in  long  bones.  Direct  violence  is  the  most  frequent  cause, 
but  breaks  due  to  indirect  violence  are  not  infrequent,  while  occasional 
cases  are  attributable  to  muscular  strain  alone.  The  character  of  dis- 
placement is  determined  largely  by  the  direction  of  the  original  break- 
ing force,  but  muscular  contraction,  also,  is  active  in  modifying  it, 
differing  in  direction  and  power  according  to  the  relation  of  the  seat  of 
fracture  to  the  muscular  attachments  and  to  the  obliquity  of  the  fracture 
itself.  Injury  to  the  brachial  blood-vessels  may  complicate  the  fracture, 
either  as  the  result  of  the  primary  violence,  or,  later,  from  the  pressure 
of  a  projecting  fragment.  Such  injury  is  fortunately  rare,  but  as  it  may 
be  the  cause  of  gangrene  in  the  distal  part  of  the  extremity,  its  possi- 
bility should  be  kept  in  mind  in  cases  of  crushing  injuries  of  the  arm, 
lest  blame  for  the  subsequent  unavoidable  gangrene  should  be  improp- 
erly imputed  to  the  treatment  used.  In  like  manner,  the  principal 
nerve-trunks  may  be  injured.  The  musculospiral  nerve,  from  its  close 
relation  to  the  bone  through  so  large  a  part  of  its  course,  is  especially 
exposed  to  such  injury,  or  is  liable  later  to  become  enclosed  and 
compressed  by  exuberant  callus. 

The  diagnosis  of  fracture  of  the  shaft  presents  no  difficulties  ;  the  typ- 
ical signs  of  fracture  declare  themselves  to  the  most  casual  examination. 

The  prognosis  should  always  be  guarded,  for  although  in  most  cases 
strong  consolidation  of  the  fracture  occurs  as  soon  as  in  other  long 
bones,  yet  failure  of  bony  union  is  more  frequent  in  this  region  than  in 
any  other  part  of  the  skeleton,  except  the  patella.  Agnew,  in  his 
treatise  on  surgery,  gives  the  results  of  a  search  through  literature  for 
reports  of  cases  of  ununited  fracture.  Of  the  cases  collated  by  him, 
the  more  important  regions  give,  of  the  bones  of  the  forearm,  76  cases  ; 
of  the  thigh,  131  ;  of  the  leg,  180;  of  the  arm,  219.  Various  reasons 
have  been  suggested  in  explanation  of  this  special  frequency  of  repara- 
tive failure  in  the  humerus,  but  it  is  not  necessary  to  go  further  than 
defective  immobilization,  due  to  common  methods  of  treatment,  whereby 
the  lower  fragment  and  the  forearm  are  converted  into  a  continuous 
long  lever,  the  inevitable  frequent  movements  of  whose  distal  end  are 
transmitted  to  the  point  of  fracture,  and  are  not  controlled  by  sufficient 
firmness  or  extent  of  grasp  of  the  dressings  upon  the  upper  fragment. 
Some  shortening  is  inevitable  in  oblique  fractures,  but  of  itself  is  of  no 
importance,  since  it  does  not  interfere  with  the  normal  function  of  the 
arm.  Rotary  displacement  is  of  more  importance,  but  can  be  guarded 
against  by  observing  the  precaution,  when  applying  the  dressings,  to 
see  that  a  line  drawn  from  the  greater  tuberosity  to  the  external  condyle 
is  parallel  to  the  axis  of  the  shaft  of  the  bone. 

Treatment. — Reduction  of  any  displacement  is  first  to  be  secured  by 
extension  and  manipulation  ;  when  the  break  is  attended  with  extensive 
bruising  of  the  soft  parts,  as  is  not  infrequently  the  case  in  fracture  from 
direct  violence,  the  patient  should  be  kept  in  bed,  while  the  arm  is  sup- 
ported on  pillows  and  an  evaporating  lotion  kept  applied  to  the  injured 
area  until  the  primary  swelling  has  begun  to  subside — a  period  ordi- 
narily of  from  five  to  eight  days.  Meanwhile,  the  signs  of  serious 
injury  to  blood-vessels  or  nerve-trunks  should  be  sought  for,  and,  if 
found,  the  special  treatment  indicated  for  the  particular  injury  resorted 


550  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

to.  If  the  blood-supply  to  the  distal  part  of  the  extremity  is  found  to 
be  compromised,  all  dressings  that  may  produce  constriction  or  pressure 
must  be  absolutely  discarded. 

Signs  of  finger-  and  wrist-paralysis  should  be  carefully  sought  for 
both  in  the  primary  examination  in  every  case  of  fracture  of  the  humerus 
and  at  the  later  dressings,  for  nerve-injury  is  more  frequently  occasioned 
by  later  pressure  from  a  displaced  fragment,  or  by  involvement  in  the 
exuberant  callus  attending  imperfect  reduction,  or  by  the  pressure  of 
the  dressings  applied,  than  by  the  original  fracturing  force.  The  rear- 
rangement of  dressings  to  avoid  pressure,  and  whatever  procedure  may 
be  required  to  secure  a  more  complete  restoration  of  the  proper  relations 
of  the  fragments,  even  to  incision  and  suture  if  necessary,  should  follow 
at  once  the  discovery  of  signs  of  nerve-pressure.  In  cases  of  later 
imprisonment  in  callus  or  cicatricial  tissue,  the  nerve  should  be  relieved 
by  operation  at  the  earliest  possible  moment. 

Immobilization  at  the  seat  of  fracture  at  any  point  along  the  shaft  is 
best  secured  by  utilizing  the  wall  of  the  thorax  as  an  internal  splint, 
bandaging  the  arm  to  it.  The  movements  of  respiration  and  the 
unavoidable  bendings  of  the  trunk  do  not  create  such  motion  at  the 
seat  of  fracture  as  to  disturb  the  progress  of  repair.  Between  the 
thoracic  wall  and  the  arm  should  be  interposed  a  soft  compress,  which 
should  be  graduated  in  thickness  at  various  parts,  so  as  to  fill  up  the 
intervening  space  fully  and  afford  even  support  to  the  humerus.  To  the 
outside  of  the  arm,  from  shoulder  to  elbow,  should  be  moulded  the 
plaster-of-Paris  splint  described  in  the  preceding  section.  In  cases  of 
fracture  at  the  middle  of  the  shaft,  a  coaptation  splint  of  wood,  long 
enough  to  reach  from  axilla  to  condyle,  and  of  a  breadth  slightly 
exceeding  the  diameter  of  the  arm,  well  padded  with  cotton  wool, 
should  be  adjusted  to  the  inner  side  of  the  arm,  and  secured  in  place 
by  three  strips  of  adhesive  plaster  made  to  encircle  the  external  plaster 
splint.  The  arm  is  now  to  be  bandaged  to  the  side  of  the  thorax  by  a 
roller  which,  beginning  just  above  the  elbow,  gradually  ascends  with 
successive  turns  until  it  has  enclosed  the  shoulder.  The  forearm 
should  then  be  brought  in  front  of  the  chest  at  a  slightly  acute  angle, 
the  comfort  of  the  patient  being  consulted  as  to  the  exact  position,  and 
fixed  in  place  by  a  separate  roller,  which  should  cover  in  only  the 
anterior  half  of  the  forearm.  By  this  dressing  the  elbow  is  left  uncov- 
ered, any  tendency  to  press  the  lower  fragment  upward  is  avoided,  and 
the  use  of  the  weight  of  the  forearm  for  continuous  extension  is  in 
some  degree  preserved.  Should  marked  shortening  persistently  recur 
after  reduction,  this  natural  extension  force  can  be  increased  by  slinging 
such  amount  of  weight  from  the  elbow  as  may  be  necessary  to  over- 
come the  tendency  to  shortening.  In  fractures  through  the  lower  third 
of  the  shaft,  the  lower  fragment  is  apt  to  be  tilted  forward  by  the 
action  of  the  triceps  muscle  and  the  weight  of  the  forearm.  To  over- 
come this  tendency  it  is  necessary  to  place  the  elbow  at  a  more  acute 
angle  for  the  first  two  weeks. 

Non-union. — Should  firm  union  fail  to  be  secured  by  the  treatment 
described  by  the  end  of  six  weeks,  massage  and  hammering  over  the 
site  of  the  fracture  may  be  applied  twice  each  week,  the  immobilization 
of  the  parts  being  maintained  in  the  intervals.     If,  after  from  four  to 


SEE  CIA  L    ERA  C  TURES. 


551 


six  weeks  of  this  special  treatment,  union  is  still  delayed,  the  fracture 
should  be  exposed  by  suitable  incision  in  the  long  axis  of  the  limb, 
and  the  ends  of  the  bones  freshened  and  dovetailed  into  each  other 
and  fastened  together  by  heavy  silyer-wire  sutures.  A  more  exact 
retention  of  the  bone-ends  in  apposition  can  be  secured  by  the  device 
of  White,  who  used  a  steel  plate  f-  inch  wide  and  3  inches  in  length, 
pierced  by  two  screw-holes  in  each  half.  This  plate  is  placed  upon 
the  surface  of  the  apposed  denuded  bone-fragments,  and  secured  by 
screws  which  are  driven  into  holes  in  the  bone  made  by  a  drill.  At 
the  end  of  six  or  eight  weeks,  the  soft  parts  are  again  divided  suf- 
ficiently to  enable  the  surgeon  to  remove  the  screws  and  withdraw  the 
plate.  In  all  these  procedures  special  care  is  required  to  avoid  injury 
to  the  main  vessels  and  nerves  of  the  arm. 

Fractures  of  the  lower  extremity  of  the  humerus  are  of  frequent 
occurrence,  both  from  the  direct  force  of  falls  upon,  or  blows  received 
by,  the  elbow,  and  the  indirect  force  of  falls  upon  the  outstretched 
hand.  They  are  especially  frequent  during  childhood.  The  line  of 
fracture  may  extend  transversely  above  the  condyle  or  through  the 
epiphyseal  line  in  young  subjects ;  it  may  be  limited  to  the  chipping 
away  of  a  small  fragment  of  either  condyle,  or  the  fracture  may  sepa- 
rate the  entire  mass  of  the  condyle  and  open  into  the  cavity  of  the 
elbow-joint.  By  the  comminution  of 
the  lower  fragment  a  transverse  supra- 
condyloid  fracture  may  communicate 
with  the  elbow-joint  through  a  longi- 
tudinal line  of  fracture  (Fig.  237).  Dis- 
location of  the  ulna  or  radius  at  the 
elbow  is  a  not  infrequent  complication  ; 
and  fracture  of  the  upper  end  of  the 
radius  or  ulna  is  an  occasional  con- 
comitant of  any  of  the  above-mentioned 
fractures  of  the  humerus,  the  injuries 
being  the  result  of  severe  crushing  vio- 
lence, and  often  compound  in  character. 

The  involvement  of  the  elbow-joint, 
either  directly  or  indirectly,  gives  espe- 
cial gravity  to  fractures  of  the  lower  end 
of  the  humerus.  Some  limitation  of  the 
motions  of  this  joint  is  the  rule  after 
fracture  in  its  vicinity,  and  complete 
ankylosis  is  not  infrequent.  The  exact 
retention  of  the  fragments  in  their  proper 
positions  is  difficult  to  maintain,  owing 
to  the  leverage  of  the  bones  of  the  fore- 
arm with  which  the  lower  fragment 
remains  attached ;  and  slight  displace- 
ment is  enough  to  alter  materially  the 
symmetry  of  the  elbow,  and  often  to 
impair  its  function  by  occasioning  a  me- 
chanical obstacle  to  the  full  normal  range  of  motion.  Even  in  the 
absence  of  malposition,  new-formations  of  bone  from  exuberant  callus 


Fig.  237. —  Supracondyloid  trans- 
verse fracture  of  the  lower  end  of  the 
humerus,  with  longitudinal  fissure  into 
the  elbow-joint  (T-fracture). 


552 


1NTERXATIONAL    TEXT-BOOK  OE  SURGERY. 


may  produce  the  same  effect,  or  may  absolutely  ankylose  the  joint. 
Some  thickening  and  contraction  of  the  capsular  and  peri-articular 
tissues,  as  the  immediate  result  of  the  injury,  is  usual  and  unavoidable; 
and  when  true  inflammation  is  provoked  by  infection  or  repeated  trau- 
matism, permanent  contractures  and  adhesions,  that  may  produce  a 
prolonged  or  even  definitive  limitation  of  motion,  are  likely  to  result. 

Oblique  fracture  of  a  condyle,  the  line  of  fracture  entering  the  joint, 
is  the  most  common  variety  of  fracture.  Both  condyles  seem  to  be 
about  equally  exposed  to  fracture.  The  direction  of  the  line  of  fract- 
ure separating  the  internal  condyle  is  a  fairly  uniform   one,  beginning 


Fig.  238. — Fracture  of 
the  internal  condyle 
(Hamilton). 


Fig.  239. — Fracture  of 
the       external      condyle 

(Hamilton). 


FIG.  240. — Fracture  above  the 
condyles,  with  longitudinal  fissure 
into  elbow-joint  (Hoffa). 


somewhat  above  the  base  of  the  epicondyle,  and  extending  obliquely 
outward  and  downward  through  the  olecranon  and  coronoid  fossae  to 
the  center  of  the  trochlear  surface.  The  contractions  of  the  triceps 
and  brachialis  anticus  muscles  upon  the  ulna  tend  to  pull  it  and  its 
attached  condyloid  fragment  upward  as  far  as  the  attachments  of  the 
radius  will  allow.  This  tendency  to  upward  displacement  is  increased 
by  any  pressure  upon  the  under  surface  of  the  olecranon  or  by  lateral 
movements  of  the  forearm  internally.     Some  rotation  of  the  condyloid 


FlG.  241. — Gunstock  deformity  at  elbow,  following  fracture  of  either  condyle  of  the 

humerus  (Allis). 


fragment  with  anterior  displacement  is  caused  by  extending  the  fore- 
arm. The  effect  of  any  upward  displacement  is  to  lessen  the  normal 
humero-ulnar  anele  and  to  convert  it  into  an   abnormal  one   in   the 


SPECIAL    FRACTURES.  553 

opposite  direction,  producing  the  deformity,  familiar  by  its  frequency, 
called  the  "gunstock"  deformity,  shown  in  Fig.   241. 

The  external  condyle  may  be  detached  by  a  line  of  fracture  that 
enters  the  joint  at  some  point  of  the  capitellum,  or  that  extends  more 
internally  to  the  trochlea.  The  extensor  and  pronator  muscles  that 
arise  from  it  tend  to  pull  it  forward  and  downward,  while  the  mobility 
of  the  condyle  permits  internal  lateral  deflection  of  the  forearm  at  the 
elbow,  producing  again  loss  of  the  normal  humero-ulnar  angle  and  the 
gunstock  deformity. 

In  supracondyloid  transverse  fractures,  the  lower  fragment  is  usually 
displaced  backward  and  is  drawn  upward  behind  the  lower  end  of  the 
upper  fragment.  The  deformity  simulates  very  closely  that  produced 
by  backward  dislocation  of  the  bones  of  the  forearm  at  the  elbow,  and 


FIG.  242. — Supracondyloid  fracture  of  the  humerus,  lower  part  displaced  backward ; 
epiphysis  of  the  olecranon  indicates  the  youthful  age  of  the  patient  (Morton)  (skiagraph  by 
Goodspeed). 

in   the   presence   of    swelling   and   muscular   rigidity   requires    careful 
examination  for  its  discrimination. 

The  line  of  separation  may  follow  the  epiphyseal  line,  in  which  case 
the  fragment  formed  by  the  epiphysis  may  still  more  readily  escape 
recognition  by  reason  of  its  thinness.  The  replacing  of  the  fragments 
in  their  proper  relations  to  each  other  is  easily  accomplished  by  exten- 
sion and  manipulation  while  the  elbow  is  flexed  at  a  right  angle,  but 
the  displacement  tends  at  once  to  recur  as  soon  as  the  retaining  forces 
are  removed.  Union  may  take  place  with  the  fragments  incompletely 
reduced,  causing  a  permanent  mechanical  obstacle  to  the  full  flexion  of 
the  elbow.  Rotary  displacement  of  the  lower  fragment,  induced  by  the 
leverage  of  the  forearm  bones,  may  readily  occur,  unless  care  is  taken 
to  avoid  it  in  the  course  of  treatment.  Supracondyloid  fracture  with 
comminution  of  the  lower  fragment  results  from  violence  of  special 


5  54 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


Fig.  243. 


-Supracondyloid  fracture  of  the 
humerus  (Hoffa). 


severity,  and  is  often  accompanied  by  lacerations  of  the  overlying  soft 
parts,  that  expose  the  fracture  to  septic  infection.  Even  in  the  absence 
of  infection,  the  effusion  into  and  about  the  joint  is  extreme  in  amount, 

the  development  of  callus  is  espe- 
cially liable  to  be  excessive  and  so 
placed  as  to  interfere  with  the  func- 
tion of  the  joint,  and  the  difficulties 
attending  the  proper  reduction  and 
retention  in  place  are  so  great  that 
marked  deformity  is  often  unavoid- 
able. 

The  tip  of  either  condyle  may  be 
chipped  off  by  a  direct  blow,  and 
may  become  displaced  downward  by 
muscular  traction.  The  line  of  fract- 
ure does  not  involve  the  joint,  nor 
does  the  displacement  impair  func- 
tion. The  injury  is  a  relatively  in- 
significant one. 

The  diagnosis  of  fractures  at  the 
lower  end  of  the  humerus  requires 
for  its  satisfactory  establishment  care- 
ful and  minute  comparison  of  the 
anatomical  landmarks  of  the  region. 
These  are  often  obscured  by  the  great  swelling  that  quickly  follows  inju- 
ries at  the  elbow,  and  their  satisfactory  examination  can  often  only  be 
done  under  general  anesthesia,  especially  in  the  cases  of  children,  in 
whom  most  of  these  fractures  occur.  Supracondyloid  fracture  is  to  be 
distinguished  from  backward  dislocation  of  the  ulna  and  radius  by  the 
unchanged  relations  of  the  condyles  and  the  olecranon,  by  the  recog- 
nition of  the  irregular  outline  presented  by  the  projecting  surfaces  of 
the  displaced  fragments,  by  the  shortening  of  the  humerus,  proven  by 
measurement  from  the  tip  of  the  acromion  to  the  condyle,  by  the  facility 
of  reduction  followed  by  tendency  to  redisplacement,  and  by  the  crepitus 
elicited  when  the  fragments  are  brought  down  into  place.  The  presence 
and  location  of  oblique  condyloid  fractures  is  best  determined  by  grasp- 
ing the  lower  end  of  the  humerus  by  the  fingers  of  one  hand,  and  with 
the  other  rocking  the  bones  of  the  extended  forearm  from  side  to  side ;. 
the  broken-off  condyle  is  felt  to  move  with  the  bones  of  the  forearm, 
producing  a  lateral  mobility  at  the  elbow,  which  is  never  present  in  the 
normal  condition  of  the  joint.  Crepitus  is  elicited  by  these  maneuvers,, 
and  the  presence  and  extent  of  displacement  are  appreciated  by  pal- 
pation. 

In  the  treatment  of  all  fractures  at  the  lower  extremity  of  the 
humerus,  accurate  and  speedy  reposition  of  the  fragments  is  of  high 
importance.  This  can  usually  be  readily  effected  by  manipulation  and 
extension  while  the  elbow  is  flexed  at  a  right  angle,  in  which  position 
the  most  general  relaxation  of  the  tissues  in  and  about  the  joint  is 
present.  As  to  later  retention,  this  position  has  the  disadvantage  that 
the  relaxed  tissues  favor  consecutive  renewed  displacement,  which  may 
be   caused  by  the  mere  pressure  of  dressings  and  the  weight  of  the 


SPECIAL   FRACTURES. 


555 


VkM* 


extremity  supported  in  the  customary  sling,  even  in  the  absence  of 
muscular  contraction  and  deviations  of  the  bones  of  the  forearm  from 
their  proper  axis.  By  placing  the  forearm  in  the  extended  position  the 
humero-ulnar  angle  can  be  kept  under  control ;  but  some  anterior 
rotation  of  a  condyloid  fragment  is  inevitable,  and  some  posterior  and 
rotary  displacement  of  the  lower  fragment  in  cases  of  supracondyloid 
fracture  is  difficult  to  prevent,  the  probabilities  of  later  functional 
impairment  of  the  joint  are  increased,  and  in  cases  of  ankylosis  the 
position  of  the  joint  is  the  most  objectionable  that  could  be  produced. 
H.  L.  Smith  has  shown  that  in  all  cases  of  fracture  of  the  lower 
extremity  of  the  humerus,  the  posi- 
tion in  which  the  fragments  are  held 
most  firmly  in  place  and  are  least 
susceptible  to  displacement  from 
forces  acting  from  without  is  that  of 
flexion  at  an  angle  as  acute  as  the 
comfort  of  the  patient  will  allow. 
In  this  position  the  fragments  are  all 
held  locked  between  the  coronoid 
process  in  front  and  the  ligamentous 
and  musculotendinous  structures 
behind.  Unless  proper  adjustment 
of  the  fractured  surfaces  has  been 
secured,  full  flexion  at  the  elbow 
cannot  be  made,  so  that  it  is  essential 
that  this  adjustment  be  first  secured 
before  attempting  to  bring  the  fore- 
arm into  the  acute  flexion  required. 
The  fragments  having  been  adjusted 
and  the  forearm,  semi-prone,  brought 
up  into  full  flexion,  it  remains  only 
to  hold  the  forearm  in  this  position  by 
a  broad  figure-of-8  bandage  around  the  elbow  and  body,  as  shown  in  Fig. 
244.  No  further  retentive  dressing  is  required.  Should  the  acuteness  of 
the  flexion  be  found  to  be  so  sharp  as  to  interfere  with  the  distal  arterial 
supply,  or  should  it  become  painful  on  account  of  later  swelling,  the  angle 
must  be  made  greater ;  otherwise,  the  original  position  should  be  main- 
tained until  consolidation  of  the  fracture  is  well  advanced.  In  cases  of 
open  infected  fracture,  the  same  position  should  be  maintained,  abundant 
access  to  the  elbow  for  the  necessary  special  dressings  being  afforded. 
In  the  latter  case,  before  final  consolidation  has  supervened,  in  view  of 
probable  ankylosis,  the  forearm  should  be  dropped  to  the  angle  most 
convenient  for  the  future  usefulness  of  the  hand.  Should,  for  any 
reason,  the  position  of  acute  flexion  described  be  found  to  be  intoler- 
able or  inadvisable,  the  forearm  may  be  brought  down  to  the  position 
of  a  right  angle  and  immobilized  by  a  plastic  splint,  preferably  of 
canton  flannel  or  similar  material  saturated  with  plaster-of-Paris  cream, 
moulded  to  the  anterior  surface  of  the  arm  and  forearm,  reaching  from 
axilla  to  wrist,  and  embracing  two-thirds  of  the  circumference  of  the 
limb.  An  angular,  narrow  strip  of  metal  should  be  incorporated  in 
this  splint  to  reinforce  it. 


Fig.  244. — Figure-of-8  elbow  bandage 
for  immobilizing  forearm,  with  acute 
flexion  of  elbow  (Lund). 


556 


INTERNATIONAL    TEXT-BOOK   OE  SURGERY. 


No  essay  at  passive  motion  should  be  made  before  the  fourth  week, 
and  even  then  it  should  be  restricted  to  that  range  of  motion  which 
can  be  made  without  the  use  of  force  and  without  causing  pain. 
Earlier  and  forcible  attempts  at  mobilization  disturb  the  adjustment  of 
the  fragments,  increase  the  amount  of  callus-formation  and  of  the 
inflammatory  exudation  into  and  about  the  joint,  and  exaggerate  the 
danger  of  ultimate  permanent  ankylosis.  By  the  sixth  week  all  dress- 
ings may  usually  be  laid  aside  and  active  use  of  the  extremity  be 
resumed.  The  moderate  stiffness  generally  present  gradually  dis- 
appears spontaneously  within  a  few  weeks.  If  an  ankylosis  due  to 
newly  formed  bands  of  adhesion  is  found  to  persist,  later  forcible  rupture 
under  ether  must  be  done.  Masses  of  excessive  callus  or  bone- 
fragments  healed  in  malposition,  interfering  with  the  useful  motion  of 
the  joint,  call  for  incision  and  the  chisel  for  their  removal. 

The  Bones  of  the  Forearm. — Fractures  of  the  bones  of  the 
forearm  fall  naturally  into  three  groups:  I.  Those  in  the  vicinity  of 
the  elbow  ;  2.  Those  involving  the  shaft  of  one  or  both  bones  ;  3.  Those 
at  the  wrist.  Of  the  first  group,  the  most  frequent  injury  is  fracture 
of  the  olecranon  process  of  the  ulna,  more  rarely  that  of  the  head  or 


Fig.  245. — Fracture  of  the  olecranon,  with  displacement  (Hoffa). 


neck  of  the  radius,  and  still  more  rarely  that  of  the  coronoid  process 
of  the  ulna.  Combination  of  one  or  more  of  these  fractures  with 
fracture  of  the  lower  extremity  of  the  humerus,  or  with  dislocation  at 
the  elbow,  is  occasionally  met  with. 

The  olecranon  may  be  fractured  either  by  direct  force  applied  to 
the  point  of  the  elbow,  or  by  cross-breaking  strain  exerted  through 
the  forearm  as  a  lever  while  the  triceps  is  in  tense  contraction. 

The  liability  to  displacement  of  the  upper  fragment  by  the  con- 
tractions of  the  triceps  muscle  will  depend  upon  the  extent  to  which 
the  tendino-aponeurotic  fibers,  which  closely  invest  the  process,  are 
lacerated.  When  these  are  freely  torn,  the  bone-fragment  may  be 
drawn  upward  to  the  extent  of  an  inch  or  more,  the  displacement  being 
increased  by  flexion  of  the  joint.  Fractures  by  direct  force  present 
the  least  degrees  of  aponeurotic  laceration,  and  as  a  class  the  least  dis- 


SPECIAL    FRACTURES. 


557 


if  triceps. 


Superior  fragment. 


placement.  Whenever  there  is  much  separation  of  the  fragments,  their 
fracture-surfaces  become  more  or  less  fully  invested  by  a  fringe-like 
apron  of  the  stretched  and  lacerated  aponeurosis  which  has  dropped 
down  into  the  gap  and  remains  as  an  obstacle  to  full  coaptation  and 
osseous  union. 

The  symptoms  produced  by  the  injury  are  diminution  or  loss  of  the 
power  of  extending  the  forearm,  with  pain  and  tenderness  at  the  point 
of  injury,  mobility  of  the  detached  fragment  when  manipulated  by  the 
surgeon,  and  deformity  in  many  cases  caused  by  the  upward  displace- 
ment of  the  detached  fragment,  leaving  a  gap  where  the  point  of  the 
elbow  should  be,  as  shown  in  Fig.  245.  Crepitus  may  or  may  not  be 
elicited,  according  to  the  absence  or  presence  of  fibrous  tissue  between 
the  fragments  when  they  are  brought  together.  More  or  less  ecchy- 
mosis  early  declares  itself,  together  with  marked  effusion  into  and  about 
the  elbow-joint.  The  prominence  of  the  process  and  its  subcutaneous 
position  render  the  diagnosis  of  its  fracture  easy.  The  repair,  when  the 
fracture  is  not  open  and  infected,  ordinarily  progresses  without  special 
complication.  The  swelling  subsides  promptly,  and  union  may  be 
secured  by  the  fourth  week,  with  fair 
restoration  of  function  after  the  disap- 
pearance of  the  peri-articular  rigidity ; 
some  limitation  to  full  normal  extension 
is  an  occasional  permanent  sequel.  Bony 
union  is  frequently  prevented  by  the 
interposition  of  fibrous  material  between 
the  fragments  (Fig.  246). 

In  the  treatment,  if  the  fibrous  attach- 
ments of  the  fragments  are  sufficiently 
intact  to  hold  them  together,  so  that  the 
upper  fragment  is  not  separated  from 
the  lower  in  moderate  flexion,  the  limb 
may  be  immobilized  in  the  partly  flexed 
position,  which  will  be  greatly  to  the 
comfort  of  the  patient.  If,  however, 
such  flexion  separates  the  fragments,  or 
the  upper  fragment  is  already  drawn 
upward,  the  forearm  must  be  kept 
extended  until  consolidation  has  become 
firm.  The  extended  position  alone  is 
usually  sufficient  to  bring  the  fragments 
into  apposition.  If  position  fails  to  bring 
the  fragments  together,  it  has  been  rec- 
ommended to  attempt  to  pull  the  upper 
fragment  down,  and  hold  it  in  place  by  a  strip  of  adhesive  plaster  so 
applied  to  the  skin  above  it  that  downward  traction  may  be  made  by 
the  two  ends  of  the  plaster,  which  are  then  secured  to  the  front  of  the 
forearm  below.  Such  a  device  has,  however,  but  little  control  over  the 
underlying  bone-fragment  unless  it  so  completely  encircles  the  limb 
that  it  unduly  constricts  it,  and  inevitably  so  aggravates  the  local  con- 
gestion and  exudation  into  and  about  the  elbow-joint  as  to  endanger  its 
later  function  more  than  would  the  formation  of  the  fibrous  union  which 


Fig. 


246. — Fracture  of  the  olecranon, 
with  fibrous  union  (Anger). 


558 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


it  is  intended  to  prevent.  It  is  better,  if  the  fragment  cannot  be  kept 
down  in  place  by  position,  that  the  fracture  should  be  exposed 
by  incision,  and  accurate  coaptation  secured  by  sutures  after  the 
removal  of  all  fibrous  tissue  and  blood-clot  from  the  face  of  the 
fracture-surfaces.  Usually  it  will  be  possible  to  bring  and  hold 
together  the  fragments  by  chromicized  catgut  sutures  applied  to  the 
periosteum    and    tendino-aponeurotic    coverings    only.     Should    these 


Fig.  247. — Greenstick  fracture  of  the  shaft  of  the  ulna,  with  fracture  through  the  epiphyseal 
line  of  the  head  of  the  radius,  and  marked  displacement  outward  of  the  upper  end  of  the 
diaphysis  of  the  radius,  simulating  dislocation  of  the  head  of  the  radius  (skiagraph  by  Stewart). 

prove  insufficient,  silver-wire  sutures  may  be  inserted  through  the  bone- 
substance.  If  the  fracture  is  already  exposed  by  a  wound,  suturing  is 
indicated  as  a  routine,  coupled  with  abundant  provision  for  free  primary 
drainage,  which  will  have  to  be  prolonged  should  infection  not  be 
escaped.  As  in  other  joint-fractures,  such  effusion  into  the  joint  and 
swelling  of  the  surrounding  tissues  may  supervene  as  to  require  that 
treatment  at  first  be  limited  to  placing  the  limb  in  as  comfortable  a  posi- 
tion as  possible  upon  a  pillow  and  applying  to  it  evaporating  lotions,  or 
a  bag  of  ice,  until  the  primary  local  reaction  has  subsided. 


SPECIAL   FRACTURES. 


559 


For  immobilizing  the  elbow  during  repair,  a  well-padded  splint  is  to 
be  adjusted  to  the  anterior  surface  of  the  forearm  and  arm,  and  secured 
by  a  roller  bandage.  By  the  end  of  the  fourth  week  the  splint  may  be 
dispensed  with,  and  massage  and  movements  instituted. 

The  coronoid  process  may  be  chipped  off  by  being  driven  against 
the  articular  surface  of  the  humerus  in  the  act  of  a  dislocation  back- 
ward of  the  ulna.  Such  injury  is  infrequent.  Still  more  rarely  this 
process  has  been  found  to  have  been  torn  away  as  a  part  of  the  injury 
resulting  from  a  crush  of  the  elbow.  The  fragment  will  usually  retain 
sufficient  attachments,  through  untorn  periosteal  and  tendinous  fibers, 


■HBfe: 


J 


Fig.  248. — Fracture  of  radius  and  ulna 
near  their  lower  end ;  anteroposterior 
view.  Epiphyseal  cartilages  especially 
distinct,  outlining  the  lower  epiphyses 
(Warren).  For  lateral  view  of  same  in- 
jury, see  Fig.  249. 


Fig.  249. — Fracture  of  bones  of  the  forearm 
near  their  lower  extremity,  with  posterior  dis- 
placement of  the  lower  fragment  (Warren). 


to  prevent  much  displacement.  If  examination  is  made  before  much 
swelling  has  supervened,  it  may  be  appreciated  as  a  movable  mass  at 
the  bend  of  the  elbow,  by  the  manipulation  of  which  crepitus  may  be 
elicited.  In  cases  of  coexistent  dislocation,  the  dislocation  is  readily 
reducible  and  as  readily  recurs.  Repair  by  bony  union  is  to  be  expected 
under  proper  treatment.  The  treatment  required  is  fixation  of  the  elbow 
in  acute  flexion,  as  already  described  for  the  injuries  involving  the  lower 
end  of  the  humerus. 

The  head  of  the  radius  may  have  more  or  less  of  its  articular  rim 
split  off  by  the  same  forces  as  have  just  been  mentioned  in  connection 
with  the  coronoid  process  of  the  ulna ;  the  two  injuries  may  occur  coin- 


560 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


cidently.  The  special  symptoms  to  which  this  injury  gives  rise  are  pain 
and  crepitus,  caused  by  efforts  at  rotation.  In  some  cases  the  detached 
fragment  has  been  appreciable  as  a  movable  piece  lying  between  the 
olecranon  and  the  head  of  the  radius. 

The  line  of  fracture  may  be  more  or  less  transverse  through  the 
neck  of  the  radius,  or  through  the  epiphyseal  line  in  young  subjects 
(Fig.  247),  in  which  case,  in  addition  to  pain  and  crepitus  on  rotation  of 
the  forearm,  anterior  displacement  of  the  upper  end  of  the  lower  frag- 
ment from  contraction  of  the  biceps  muscle  may  be  sufficient  to  cause 
a  noticeable  projection.     Fracture  at  the  upper  end  of  the  radius  may 


Fig.  250. — Fracture  of  bones  of  the  forearm,  with  angular  displacement  (Warren). 

readily  be  followed  by  total  loss  of  the  power  of  rotation,  from  obstruc- 
tion caused  by  the  fragment  healed  in  displacement,  or  from  welding 
together  of  the  radius  and  ulna  by  vicious  callus.  The  treatment  required 
is  immobilization  in  the  flexed  position. 

The  bones  of  the  forearm  along  their  shaft  are  the  frequent  sub- 
jects of  fracture,  both  from  direct  violence  and  from  the  indirect  force  of 
falls  upon  the  hand.  Instances  of  fracture  from  muscular  action  alone 
have  been  reported.  Incomplete  or  greenstick  fractures  are  met  with 
more  frequently  in  these  bones  than  elsewhere,  with  the  possible  excep- 
tion of  the  clavicle.  All  the  varieties  of  fracture  to  which  long  bones 
are  liable  may  be  presented  by  the  bones  of  the  forearm  (Fig.  248). 

Displacement,  angular  or  by  overriding,  is  common.     Lateral  dis- 


SPECIAL    FRACTURES. 


56l 


placement  from  pressure  of  dressings  or  muscular  contraction  may 
cause  such  encroachment  upon  the  interosseous  space  as  to  limit  rota- 
tion, or  by  the  welding  together  of  the  two  bones  to  destroy  it  altogether 


Fig.  251. — Compound  fracture  of  the  ulna,  with  dislocation  of  the  head  of  the  radius  (Good- 
speed). 

(Fig.  252).  When  the  point  of  fracture  in  the  radius  is  located  above 
the  insertion  of  the  pronator  radii  teres  muscle,  the  upper  fragment  is 
liable  to  become  supinated  by  the  unopposed  action  of  the  biceps, 
requiring  the  whole  forearm  to  be  kept  in  supination  until  consolidation 
is  secured,  to  avoid  the  loss  of  function  from  the  rotary  displacement. 


FlG.   252. — Fracture  of  the  radius  and  ulna,  with  exuberant  ossified  callus  uniting  the  two 

bones  (Warren  Museum). 

The  diagnosis  presents  no  difficulties,  owing  to  the  superficial  posi- 
tion of  the  bones  and  the  readiness  with  which  the  characteristic 
symptoms   of  fracture  may  be  elicited. 

The  course  of  the  healing,  as  a  rule,  is  uncomplicated  and  leads  to. 
full  bony  union  in  from  four  to  six  weeks.  The  presence  of  comminu- 
tion or  of  open  wound  with  infection  may  interfere  with  such  a  favorable 

36 


562  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

progress,  and  may  determine  either  non-union  or  such  muscular  atrophy 
and  adhesions  along  tendon-sheaths  as  to  cripple  the  limb  seriously. 
Many  instances  have  been  recorded  in  which,  by  the  pressure  of  encir- 
cling bandages,  or  of  splints  applied  without  proper  provision  for  later 
swelling  of  the  parts  or  left  without  intelligent  inspection,  gangrene  of 
the  distal  portion  of  the  limb  or  troublesome  sloughs  from  local  press- 
ure have  been  produced. 

Treatment. — Accurate  reduction  is  important,  both  for  the  preserva- 
tion of  the  symmetry  of  the  limb  and  for  the  power  of  normal  rotation. 
This  is  to  be  accomplished  by  extension  and  manipulation  while  the 
forearm  is  held  in  the  position  in  which  its  muscles  will  be  most  relaxed 
— viz.,  midway  between  pronation  and  supination,  with  moderate  flexion 
of  elbow  and  wrist.  After  reduction,  the  fragments  should  be  held  in 
position  by  two  light  wooden  splints,  one  to  the  dorsal  and  one  to  the 
palmar  aspect  of  the  forearm.  Each  should  be  well  padded  with 
cotton,  and  should  be  broad  enough  to  prevent  the  encircling  bandage 
that  holds  them  in  place  from  making  any  lateral  pressure  on  the  fore- 
arm. The  dorsal  splint  should  extend  from  the  point  of  the  elbow  to 
the  metacarpophalangeal  joint;  the  palmar  one  from  the  flexure  of  the 
elbow  to  the  flexure  of  the  wrist.  These  splints  should  be  first  fixed 
in  position  by  two  strips  of  adhesive  plaster  wrapped  about  them,  one 
near  either  end  ;  then  a  roller  bandage  should  be  applied  firmly  over 
all.  Finally,  the  forearm  should  be  placed  in  a  sling.  Frequent  inspec- 
tion of  the  limb  should  be  made  daily  for  the  first  week,  to  guard 
against  the  effects  of  pressure  or  the  possibility  of  displacement  from 
loosening  of  the  dressings.  Usually  by  the  fifth  week  the  splints  can 
be  dispensed  with  and  active  use  of  the  limb  resumed. 

Either  the  radius  or  the  ulna  alone  may  be  broken  at  any  part  of 
its  shaft  by  a  direct  blow.  Such  an  injury  is  not  uncommon.  The 
extent  and  direction  of  the  displacement,  if  any  occurs,  is  determined 
by  the  fracturing  force.  The  treatment  required  is  the  same  as  that 
already  described  in  case  of  fracture  of  both  bones.  The  tendency  of 
the  biceps  muscle  to  rotate  the  upper  fragment  of  the  radius  into 
supination,  when  that  bone  is  fractured  above  its  middle,  is  to  be  kept 
in  mind,  and  accommodated  in  such  case  by  dressing  the  forearm  in 
supination   until  consolidation  has  been  secured. 

The  bones  of  the  forearm  in  the  immediate  vicinity  of  the  wrist- 
joint  may  be  fractured  by  a  direct  crushing  force.  Such  injuries  are 
apt  to  be  accompanied  with  wound  of  the  overlying  soft  structures,  and 
to  present  such  varying  degrees  of  comminution  and  displacement  as 
to  negative  systematic  description. 

Fracture  by  indirect  force  transmitted  from  the  hand  is  of  frequent 
occurrence.  In  many  cases  the  lower  end  of  the  radius  only  is  fract- 
ured, but  not  infrequently  the  styloid  process  of  the  ulna  is  also  broken 
off,  and  in  some  cases  the  shaft  of  the  ulna  is  fractured  at  a  point  some 
distance  above.  The  frequency  with  which  the  force  of  a  fall  is  broken 
by  an  outstretched  hand  causes  fracture  of  the  radius  at  its  lower  end 
to  be  the  most  common  of  all  fractures.  The  peculiar  mechanism  of  the 
wrist-joint  is  such  as  to  give  to  these  fractures,  as  a  class,  a  quite  uniform 
type  ;  the  proximity  of  the  intricate  and  important  radio-ulnar  and  radio- 
carpal articulations  and  the  numerous  tendon-sheaths  of  the  flexors  and 


SPECIAL    FRACTURES. 


563 


extensors  of  the  wrist  and  hand  entail  special  liability  to  functional 
disability  from  adhesions  resulting  from  the  accident,  while  whatever 
deformity  may  result  is  kept  in  constant  view  by  the  superficial  and 
prominent  position  of  the  bones. 

The  lower  extremity  of  the  radius,  whenever  strong  backward  or 
forward  flexion  of  the  hand  upon  the  forearm  occurs,  is  subjected  to 
cross-breaking  strain  through  the  common  carporadial  ligaments,  ante- 
rior or  posterior,  as  the  case  may  be.  The  frequency  with  which  the 
force  of  a  fall  is  partially  sustained  by  the  outstretched  hand,  and  the 
hand  thereby  forced  into  strong  backward  flexion,  explains  the  fre- 
quency of  the  fracture  in  question.  Fig.  253  shows  the  relations  of 
the  lower  end  of  the  radius  to  the  elements  of  the  wrist-joint  when  the 
hand  is  bent  backward  until  the  anterior  ligaments  are  taut.  Further 
strain,  if  sufficiently  violent,  must  rupture  either  the  ligamentous  fibers 
or  the  bones  of  the  carpus,  or  tear  off  some  portion  of  the  lower  end 
of  the  radius.  The  projection  of  the  anterior  articular  lip  of  the  radius, 
into  which  the  ligament  is  inserted,  mechanically  favors  the  transmission 
of  the  greater  part  of  the  strain  to  that  portion  of  the  bone,  and  renders 
it  less  liable  to  resist  than  are  the  fibers  of  the  ligament  itself. 

The  manner  in  which  the  resulting  fracture  is  produced  is  shown  in 
Fig.  254. 


Fig.  253. — Diagram  showing  the  relations 
of  the  lower  end  of  the  radius  to  the  ele- 
ments of  the  wrist-joint ;  longitudinal  section 
with  the  hand  in  moderate  backward  flexion. 


FlG.  254. — Effect  upon  the  lower  end  of 
the  radius  of  the  cross-breaking  strain  pro- 
duced by  extreme  backward  flexion  of  the 
hand. 


The  amount  of  the  bone  thus  torn  off  varies  greatly  in  different 
cases,  on  account  of  the  differences  in  the  shape  and  structure  of  the 
bone,  in  the  relative  strength  of  the  different  fasciculi  of  the  ligament, 
and  in  the  amount  of  strain  and  pressure  in  action.  The  accompany- 
ing illustrations,  drawn  (Figs.  255,  256)  from  museum  specimens,  show 
some  of  these  varying  lines  of  fracture. 

In  most  cases  of  falls  upon  the  outstretched  hand  the  cross-breaking 
strain  from  the  backward  flexion  of  the  hand  is  further  complicated  by 
a  vertical  force,  due  to  the  impact  against  the  ground  of  the  weight  of 
the  body,  transmitted  through  the  limb  to  the  hand.  The  amount  of 
this  in  different  instances  must  vary  within  very  wide  limits,  depending 
upon  the  weight  of  the  particular  body  and  the  distance  and  velocity 
•of  the  fall.     An  equal  amount  of  this  force  will  also  produce  different 


564 


INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 


effects  in  different  individuals,  and  in  the  same  individual  at  different 
times.  In  many  instances,  a  cross-breaking  strain  to  the  point  of  fract- 
ure at  the  wrist  is  successfully  resisted  by  the  tissues,  and  the  compo- 
site strain  is  transmitted  higher  along  the  limb,  to  be  decomposed  ulti- 


Fig.  255.  Fig.  256. 

FIGS.  255,  256. —  Lines  of  breakage  in  fractures  of  the  lower  extremity  of  the  radius. 

mately  without  serious  injury,  or  to  produce  dislocation  or  fracture  at 
some  other  point. 

Whenever,  however,  the  tearing  away  of  more  or  less  of  the  lower 
end  of  the  radius  has  resulted,  the  effect  of  the  surviving  vertical  force 
is  to  thrust  backward  and  upward  the  fragment  that  has  been  torn  off, 


FIG.  257. —  Fracture  of  the  lower  extremity  of  the  radius  (Warren). 

and  to  impale  it  upon  the  sharp,  strong  edge  presented  by  the  thick 
compact  tissue  of  the  posterior  surface  of  the  upper  fragment. 

The  amount  of  backward  displacement  thus  produced  may  be  of 
any  degree,  from  a  slight  slip,  merely  sufficient  to  efface  the  natural 
projection  of  the  anterior  articular  lip,  to  dislocation  so  complete  that 
the  whole  of  the  lower  fragment  overrides  the  lower  end  of  the  upper. 


SPECIAL   FRACTURES. 


565 


The  degree  of  impalement  suffered  by  the  lower  fragment  is  also 
subject  to  the  widest  variations,  from  that  of  a  slight  mutual  entangle- 
ment of  the  irregular  fracture-surfaces,  to  that  of  deep  penetration 
of  the  upper  into  the  lower,  with  splitting  of  the  lower  into  many 
fragments.  Even  in  its  minor  degrees,  this  interpenetration  of  the 
fragments,  by  the  crushing  of  the  cancellous  tissue  of  the  lower 
fragment  which  attends  it,  produces  some  positive  change  in  the  form 
and  structure  of  the  lower  fragment,  which  is  essentially  a  mass  of 
spongy  tissue  enclosed  in  a  thin,  compact  shell.  As  the  result  of  this, 
some  permanent  alteration  from  the  normal  contour  of  the  bone  is 
inevitable  (Fig.  258),  with   a   more   or   less   marked    deformity  of  the 

Section  of  os  magnum.       Inferior  fragment. 


Section  of  carpal  ex- 
tremity of  the  second 
metacarpus. 


Superior  fragment. 


Fig.  258. — Showing  change  in  contour  of  the  lower  fragment,  alteration  in  direction  of  the 
articular  facet,  and  loss  of  projection  of  the  anterior  lip  consequent  upon  fracture  of  the  lower 
extremity  of  the  radius  (adapted  from  Anger). 


region  following.  Even  though  the  fragments  are  disengaged  from 
one  another,  and  put  in  their  proper  position,  the  lower  fragment 
remains  shortened,  the  direction  of  its  articular  face  is  changed, 
and,  according  to  the  degree  of  the  comminution,  it  is  broadened 
both  laterally  and  anteroposteriorly.  By  the  backward  displacement 
of  the  lower  fragment  of  the  radius  further  important  changes  in 
the  relations  of  the  other  constituents  of  the  wrist-joint  are  produced. 
The  torn-off  fragment  with  the  attached  carpus  is  forcibly  rotated  into 
supination.  The  radio-ulnar  ligaments  are  strained,  possibly  in  part 
ruptured,  and  the  lower  end  of  the  ulna  is  made  to  project  abnormally 
upon  the  front  and  ulnar  side  of  the  wrist.  The  further  strain  of  the 
continued  dorsal  flexion  falls  especially  upon  that  strong  fasciculus  of 
the  anterior  common  ligament  which  passes  obliquely  from  the  middle 
of  the  carpal  mass  to  the  side  and  base  of  the  styloid  process  of  the 
ulna.  As  a  result,  the  projection  of  the  ulna  is  intensified,  and,  in 
many  cases,  the  styloid  process  itself  is  torn  off  by  the  strain.  As 
long  as  the  displacement  of  the  radial  fragment  is  unreduced,  the 
carpus  remains  locked  in  the  position  of  supination,  and  the  anterior 
projection  of  the  head  of  the  ulna  is  perpetuated  by  the  continued 
tension  of  this  fasciculus.  When  the  hand  is  taken  up  from  the 
ground  and  allowed  to  recover  from  its  position  of  dorsal  flexion,  a 
characteristic  deformity  of  the  wrist  is  presented  (see  Figs.  259,  260), 
due  to  the  posterior  projection  of  the  carpus  and  lower  radial  fragment, 
the  anterior  projection  of  the  lower  end  of  the  upper  radial  fragment, 
and  the  antero-internal  projection  of  the  head  of  the  ulna.  Dissection 
of  the  parts  in  this  state  shows  that  the  periosteal  and  aponeurotic 


566 


INTERNATIONAL    TEXTBOOK  OF  SURGERY. 


structures  that  were  stripped  up  from  the  back  of  the  proximal  radial 
fragment,  instead  of  being  torn  across,  constitute  now  a  strong  band, 
which  is  made  tense  by  the  forward  flexion  of  the  wrist,  and  while  thus 
tense  tends  to  hold  the  fragments  in  impaction  and  hinders  their  sepa- 


FlG.  260. 


FIGS.  259,  260. — Deformity  at  the  wrist  consequent  upon  displacement  backward  of  the  lower 
fragment  of  the  radius  after  fracture  at  its  lower  extremity  (Levis). 

ration  by  traction  and  ready  reposition  by  pressure.  If  union  occurs 
without  complete  reposition  of  the  lower  fragment,  the  space  which  is 
left  between  this  detached  periosteal  layer  and  the  posterior  surface  of 
the  bone  becomes  filled  with  plastic  material,  which,  by  subsequent 


Fig.  261. — Fracture  of  the  lower  end  of  the  radius,  with  anterior  displacement  of  the  lower 
fragment  united  in  deformity  (from  specimen  in  the  Museum  of  the  Edinburgh  College  of 
Surgeons)  (Roberts). 

ossification,  so  encases  this  portion  of  the  radius  in  new  bone  that,  upon 
subsequent  section,  it  presents  the  appearance  of  deep  penetration  of 
the  lower  by  the  upper  fragment. 

Anterior  displacement  of  the  lower  fragment,  after  fracture  of  the 
lower  end  of  the  radius,  is  occasionally  met  with,  as  shown  in  Fig.  261. 


SPECIAL   FRACTURES. 


567 


This  particular  form  of  injury  has  been  recently  minutely  studied 
by  Roberts,  who  has  assembled  a  considerable  number  of  clinical 
histories  and  museum  specimens  illustrating  it.  In  a  large  proportion 
of  these  cases,  the  injury  was  known  to  have  been  occasioned  by  falls 
upon  the  back  of  the  hand,  and  may  be  referred  to  a  cross-breaking 
strain  exerted  through  the  posterior  common  ligament  of  the  wrist 
upon  the  lower  end  of  the  radius,  by  the  hand  thrown  into  extreme 
palmar  flexion.  In  a  well-marked  case,  seen  by  myself,  the  patient 
had  fallen  backward  out  of  a  wagon  to  the  ground.  The  rarity  of  falls 
upon  the  back  of  the  hand,  and  the  absence  of  any  posteriorly  pro- 
jecting articular  lip  to  exaggerate  the  force  of  strain  exerted  through 
the  ligament,  explains  the  relative  rarity  of  this  form  of  displacement. 

The  effect  of  the  direct  impact  of  the  carpus,  violently  driven 
against  the  broad,  shallow,  saucer-like  articular  surface  of  the  radius, 
is  also  to  add  a  direct  crushing  and  splitting  force  to  the  indirect  cross- 
breaking  strain  heretofore  considered.  By  this  direct  force  the  pos- 
terior  lip   may  be   crushed   off,   or  stellate    lines   of  fracture  may  be 


Fig.  262. 


Fig.  263. 


FIGS.   262,  263. — Showing  the  crushing  and  splitting  effects  of  direct  impact  of  the  carpus 
against  the  lower  articular  surface  of  the  radius. 


created,  radiating  from  a  central  point  of  the  articular  surface,  com- 
minuting the  lower  fragment,  if  a  transverse  fracture  coexists,  or  in 
other  cases  extending  upward  as  longitudinal  crevices  for  a  variable 
distance  along  the  shaft,  without  transverse  fracture  (see  Figs.  262,  263). 
The  injuries  sustained  by  the  soft  tissues  about  the  wrist-joint, 
coincident  with  the  bone-lesions  that  have  been  described,  are  exten- 
sive and  important.  The  ligaments  are  violently  stretched,  partially 
lacerated,  and  sometimes  entirely  ruptured  ;  the  synovial  sacs  of  the 
articulations  are  badly  contused,  sometimes  lacerated  and  filled  with 
blood;  the  sheaths  of  the  tendons  are  injured,  both  in  front  and  behind 
— in  front,  the  projection  of  the  ragged  edge  of  the  upper  fragment 
into  the  midst  of  the  flexor  tendons  may  lacerate  their  sheaths  and 
irritate  the  tendons ;  behind,  the  violent  stripping  up  and  continued 
tension  of  the  periosteum  is  an  injury  done  to  the  floor  of  those 
extensor  tendon-sheaths  into  the  formation  of  which  it  directly  enters. 


568  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Effusions  of  blood  and  lymph  into  the  anterior  tendon-sheaths  and 
adjacent  connective-tissue  spaces  early  produce  a  well-marked  swelling 
on  the  front  of  the  wrist,  above  the  annular  ligament,  which  exagger- 
ates the  deformity  formed  by  the  bone-displacement,  and  may  simulate 
displacement  when  none  exists.  Such  an  effusion-tumor  may  result 
from  injury  to  the  soft  parts  alone,  without  the  presence  of  any  lesion 
of  the  bone.  On  the  back  of  the  carpus  also,  some  swelling  of  sim- 
ilar character  forms,  as  a  rule.  These  effusions  are  firm,  are  slowly 
absorbed,  especially  in  the  feeble  and  aged,  and  tend  to  provoke  the 
formation  of  adhesions  along  the  course  of  the  tendons  which  they 
envelop. 

The  diagnosis  is  usually  to  be  made  from  the  deformity  present 
rather  than  from  the  recognition  of  crepitus  and  abnormal  mobility, 
which  often  are  not  to  be  elicited,  on  account  of  the  displacement  and 
impaction  and  the  resistance  of  untorn  fibrous  connecting  bands.  In 
cases  in  which  the  degree  of  displacement,  and  consequently  the  extent 
of  deformity,  is  but  slight,  careful  palpation  will  usually  enable  the 
surgeon  to  recognize  the  loss  of  the  projection  formed  by  the  anterior 
lip  of  the  sound  bone  and  some  abnormal  elevation  of  the  lower  frag- 
ment on  the  back  of  the  wrist.  In  the  absence  of  any  appreciable 
displacement,  the  lesion  of  the  bone  may  still  be  inferred,  if  pressure 
elicits  a  point  of  special  tenderness  on  the  outside  of  the  radius,  near 
the  base  of  the  styloid  process,  since  such  tenderness  at  that  point 
could  not  result  from  any  ligamentous  rupture.  Forward  displacement 
of  the  head  of  the  ulna  is  recognized  at  once  on  inspection  of  the 
wrist,  and,  when  present,  indicates  the  coexistence  of  fracture  of  the 
radius.  Fracture  of  its  styloid  process  is  indicated  by  special  tender- 
ness at  its  base ;  manipulation  may  elicit  undue  mobility  and  crep- 
itus, but  it  is  rarely  so  completely  torn  away  as  to  become  notably 
displaced. 

Fracture  without  great  displacement  is  often  overlooked,  and,  being 
regarded  as  a  simple  sprain,  is  permitted  to  heal  without  effort  to  pre- 
vent deformity.  In  cases  of  severe  injury  to  the  wrist,  accompanied 
with  ecchymosis,  local  swelling,  and  impairment  of  function,  the  pres- 
ence of  fracture  is  always  to  be  inferred,  and  only  the  failure  to  elicit 
any  of  the  signs  of  it  that  have  been  mentioned  should  warrant  the 
conclusion  that  it  is  absent. 

Fracture  with  extreme  displacement  may  be  mistaken  for  a  dislo- 
cation of  the  carpus — an  error  which  was  universal  until  within  the 
present  century.  Such  uncomplicated  dislocation  is  an  extremely  rare 
occurrence,  and  should  be  accepted  as  present  only  when  careful 
examination  has  demonstrated  beyond  question  that  the  radius  is 
intact. 

Prognosis. — Rapid  bony  union  is  the  invariable  rule,  but  the  impair- 
ment of  the  function  of  the  wrist  is  often  slowly  recovered  from,  and 
in  some  cases  the  adhesions  among  the  peri-articular  structures, 
especially  along  the  tendon-sheaths,  are  so  dense  that  for  many  months 
the  wrist  remains  rigid  and  the  movements  of  the  fingers  are  limited. 
The  amount  of  actual  deformity  that  remains  will  depend  largely  on  the 
success  of  the  efforts  to  secure  primary  accurate  reposition  of  the  dis- 
placed fragment.     In  a  considerable  proportion  of  cases,  however,  there 


SPECIAL    FRACTURES.  569 

has  been  occasioned  by  the  injury  such  actual  alteration  in  the  form  of 
the  lower  fragment  that  the  restitution  of  the  perfect  normal  contour  of 
the  part  is  impossible  by  any  treatment,  and  some  deformity  is  unavoid- 
able. The  involvement  of  the  epiphyseal  cartilage  in  the  fracture  in 
children  has  been  known  to  induce  premature  ossification  and  arrest  of 
growth  of  the  lower  end  of  the  in- 
jured bone,  with  later  gradually 
increasing  deformity,  from  its 
shortness  relative  to  its  fellow 
ulna.  The  most  common  altera- 
tion, as  the  result  either  of  incom- 
plete reduction  or  damage  to  the 
bony  structure,  is  the  loss  of  the 
anterior  projection  of  the  articular 

lip    and    the  imposition    of  a  more  Fig.  264.— Diagram  showing  change  in  the 

Or  less  backward    inclination  Upon       ?on1t°urf  ot,  the   lower  end  of  a  radius   after 
.  J~  healed  fracture ;  dotted  line  shows  the  original 

the  plane  of  the  articular  surface     normal  contour. 
(Fig.  264).     The  consequence  is  a 

perpetuation  in  some  degree  of  the  deformity  which  has  already  been 
described  as  characteristic  of  the  primary  injury.  The  inward  and  for- 
ward projection  of  the  lower  end  of  the  ulna  in  many  cases  persists, 
often  when  there  is  no  appreciable  deformity  of  the  radius,  owing  to 
the  permanent  elongation  of  the  ligaments  which  bind  it  to  the  radius, 
although  in  some  cases  coexisting  minor  changes  in  the  shape  of  the 
radius  may  be  concealed  by  the  overlying  tissues. 

The  bony  deformity,  even  when  marked,  of  itself  entails  very  little, 
if  any,  functional  disability.  The  articular  rigidity,  the  matting  of  ten- 
dons, and  the  contracture  of  ligaments  and  fibrous  bands,  due  to  the 
lacerations  and  irritations  of  these  structures  in  connection  with  the 
bony  injury,  the  persistence  of  the  exudates  that  follow,  and  the  effects 
of  prolonged  immobilization,  produce  the  chief  sources  of  disability  fol- 
lowing this  injury.  This  disability  is  particularly  prone  to  be  marked 
and  persistent  in  elderly  persons,  but  usually  ultimately  yields,  even  in 
these,  to  patient  efforts  at  massage  and  mobilization. 

Treatment. — If  displacement  exists,  its  accurate  reduction  is  of  the 
first  importance.  The  chief  obstacles  to  ready  and  perfect  reduction 
are  the  impaction  or  entanglement  of  the  uneven  surfaces  of  the  frag- 
ments, and  the  tension  of  the  untorn  periosteofibrous  band  that  still 
unites  them  at  the  back.  The  latter  can  be  overcome  at  once  by 
placing  the  hand  in  dorsal  flexion  ;  while  the  hand  is  still  in  this  posi- 
tion, extension  will  disengage  the  fragments,  and  firm  thumb-pressure 
upon  the  back  of  the  lower  fragment  will  push  it  forward  into  place. 
If  the  hand  is  then  brought  into  palmar  flexion,  the  fracture-surfaces 
fall  together  and  the  normal  contour  of  the  bone  is  restored,  the  carpo- 
ulnar  ligament  is  relaxed,  and  the  ulna  assumes  or  may  be  pressed  up 
into  proper  position  in  relation  to  the  radius.  Should  the  first  effort  to 
secure  perfect  reduction  be  unsatisfactory  in  its  results,  renewed  and 
more  thorough  attempts  should  be  made,  until  it  is  evident  that  the  best 
possible  position  of  the  fragments  has  been  secured. 

Ordinarily,  there  is  but  little  tendency  to  renewed  displacement  after 
reposition,  providing   the   part   is   protected  from  further  direct  force. 


5/0 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


Any  pressure  on  the  anterior  surface  of  the  wrist  will  bear  upon  the 
projecting  anterior  lip  of  the  lower  fragment,  and  may  crowd  that  frag- 
ment back  to  the  plane  of  the  shaft  of  the  bone.  Anteroposterior 
pressure  also  tends  to  crowd  the  soft  tissues  in  between  the  radius  and 
ulna,  and,  forcing  the  ulna  away,  to  renew  and  perpetuate  its  diastasis. 
The  first  indications  are  to  give  the  injured  part  support  and  protection, 
and  by  immobilization  and  equable  compression  to  limit  effusion  and 
promote  repair.  With  the  subsidence  of  the  primary  wound-reaction, 
especial  precautions  to  maintain  the  mobility  of  the  wrist-  and  finger- 
joints  are  indicated. 

In  very  many  cases  the  application  of  a  flannel  roller  bandage  and 
the  support  of  a  sling  will  be  all  the  apparatus  required.  A  small 
compress,  about  \  inch  in  thickness,  should  be  first  adjusted  upon  the 
front  of  the  forearm,  its  lower  edge  being  permitted  to  come  down 
nearly,  but  not  quite,  to  the  level  of  the  anterior  lip  (Fig.  265,  a).     Over 

Splin  t 


FIG.  265. — Diagram  showing  the  arrangement  of  compresses  and  splint  best  adapted  to  retain 
fragments  in  proper  position  after  reduction. 


this  the  roller  passing,  binds  the  strained  and  shattered  parts  of  the 
wrist  together  and  gives  an  agreeable  sense  of  security  and  support. 

This  circumferential  compression  is  especially  important  to  maintain 
the  lower  fragment  and  the  carpus  in  their  proper  position  to  the  ulna. 
It  is  further  reinforced  during  the  after-treatment  by  keeping  the  fore- 
arm supported  on  its  ulnar  side  in  a  narrow  sling,  which  does  not 
extend  forward  beyond  the  distal  end  of  the  ulna,  in  which  position  the 
weight  of  the  unsupported  hand  and  wrist  is  an  additional  force  tend- 
ing to  press  the  ulna  into  position.  At  this  first  dressing,  allowance 
must  be  made  for  the  primary  traumatic  swelling  that  follows  the  injury, 
and  the  bandage  must  later  be  loosened  or  cut,  if  its  constriction  becomes 
a  source  of  discomfort.  As  the  swelling  subsides,  it  should  be  tightened 
again. 

Whether  to  this  dressing  should  be  added  a  splint  will  generally 
depend  upon  what  may  be  called  collateral  circumstances.  In  cases 
of  those  who  are  quite  young,  or  are  careless,  or  are  apprehensive,  the 
additional  protection  of  a  splint  is  a  wise  precaution,  if  the  surgeon  also 
remembers  that  its  prolonged  use  may  create  finger-  and  wrist-stiffness, 
and  that  by  its  pressure  deformity  may  be  perpetuated.  For  a  young 
surgeon  also,  it  will  in  most  cases  be  more  discreet  not  to  disregard  the 
popular  sentiment  as  to  the  necessity  of  a  splint  in  the  treatment  of  a 
fracture. 

Many  special  forms  of  splints  have  been  devised  by  surgeons  for  this 


SPECIAL    FRACTURES. 


571 


injury.  Not  one  of  them  possesses  such  special  advantage  as  to  justify 
its  description  here.  A  light,  straight  splint,  such  as  can  be  extem- 
porized anywhere  from  a  pine  shingle  or  a  cigar-box,  answers  the  indi- 
cations perfectly.  Only  one  splint  should  be  used,  and  this  should  be 
applied  to  the  dorsum  of  the  wrist  and  forearm  (see  Fig.  265).  It 
should  not  be  wider  than  the  wrist  itself;  it  should  extend  below  only 
to  the  heads  of  the  metacarpal  bones,  so  that  the  fingers  shall  not  be 
confined  by  it ;  it  should  be  well  padded,  and  the  padding  should  be 
made  thicker  over  the  carpus  and  metacarpus,  so  as  to  keep  the  hand 
in  slight  flexion  while  it  is  in  place ;  it  should  be  secured  with  a  roller 
to  the  hand  and  forearm,  and  the  forearm  then  suspended  in  the  narrow 
sling  already  recommended.  From  the  third  day  the  thumb  and  fin- 
gers should  be  frequently  and  systematically  flexed,  and  after  the  first 
week  the  splint  should  be  daily  removed  and  the  wrist  massaged  and 
moved.  By  the  end  of  the  third  week,  the  splint  should  be  discarded 
altogether,  and  thereafter  active  and  passive  movements  of  the  wrist 
and  fingers,  with  massage,  ought  to  be  practised  systematically  until 
the  normal  function  of  the  parts  has  been  restored. 

Bones  of  the  Wrist  and  Hand. — One  or  more  of  the  carpal 
bones  is   occasionally  broken   by  direct  violence ;  more  frequently  the 


Fig.  266. — Fracture  of  the  metacarpal  bone  (Warren) 


carpal  lesion  is  a  minor  incident  in  the  midst  of  an  extensive  crushing 
injury  of  the  wrist.  Fracture  of  the  scaphoid,  the  semilunar,  or  the  os 
magnum  has  in  different  instances  been  noted  as  a  complication  of  a 
fracture  of  the  lower  extremity  of  the  radius.  In  the  absence  of  notice- 
able displacement,  a  fracture  of  a  carpal  bone  may  easily  be  overlooked, 
the  symptoms  of  contusion  and  sprain  being  so  marked  as  to  obscure 
the  possible  signs  of  the  fracture. 

In  the   treatment,  after  any  displacement   has    been   corrected   by 
pressure,  the  subsequent  care  should  be  conducted  on  the  lines  already 


5/2  INTERNATIONAL    TEXTBOOK  OF  SURGERY. 

laid  down   in   connection  with  fractures  of  the  lower  extremity  of  the 
radius. 

The  metacarpal  bones  are  often  broken,  either  by  direct  violence  or 
indirectly,  by  force  applied  at  the  knuckles,  as  in  striking  a  blow  with 
the  closed  fist.  The  phalanges  are  often  involved  in  crushing  injuries, 
and  are  often  the  subject  of  simple  fracture  from  direct  violence. 

In  the  treatment  of  fractures  of  the  bones  of  the  hand,  immobiliza- 
tion upon  a  palmar  splint  is  indicated.  The  splint  should  extend  half- 
way up  the  forearm  above,  and  beyond  the  tips  of  the  fingers  below. 
It  should  be  padded  so  as  to  fit  the  normal  inequalities  of  the  palmar 
surface  of  the  hand  and  afford  even  support  to  the  injured  bone.  In 
dealing  with  the  frequent  compound  and  crushing  injuries  of  the  hand, 
no  fragment  of  bone  that  is  not  wholly  separated  from  its  vascular 
connections  should  be  removed,  but  all  fragments  should  be  adjusted 
as  well  as  possible,  and  so  supported  as  to  secure  consolidation  with 
the  minimum  of  deformity,  leaving  to  a  later  period  the  removal  of 
parts  that  time  and   use  may  show  to  be  useless  and  unsightly. 

The  Pelvis. — Fracture  of  the  bones  of  the  pelvis,  at  any  point  in 
their  extent,  may  result  from  direct  violence.  Disruption  of  a  pelvic 
articulation,  with  irregular  tearing  away  of  some  part  of  the  adjacent 
bony  substance,  is  relatively  frequent.  Any  of  the  various  processes  of 
the  innominate  bones  may  be  broken  without  fracture  of  the  pelvic 
girdle  proper.  The  iliac  wings,  by  reason  of  their  prominence,  are  most 
exposed  to  fracturing  violence. 

The  pubic  bone  is  the  part  of  the  true  pelvic  girdle  most  frequently 
broken.  Thus,  out  of  18  cases  of  pelvic  fracture  received  at  the  Methodist 
Episcopal  Hospital,  New  York,  within  nine  years,  in  6  the  fracture  was 
confined  to  the  iliac  wings,  in  4  there  were  extensive  multiple  fractures, 
in  1  there  was  a  diastasis  of  the  symphysis  pubis,  in  1  both  pubis  and 
ilium  were  involved  in  the  fracture,  in  3  the  pubic  bone  or  bones  only 
were  broken,  in  I  there  was  a  fracture  of  the  ilium  and  ischium  with 
diastasis  of  a  sacro-iliac  articulation,  and  in  2  the  injury  seemed  to  be 
a  sacro-iliac  diastasis   only. 

The  nature  of  the  violence  sustained  in  these  cases  illustrates  well 
the  character  of  the  more  common  causes  of  fracture  of  the  pelvic 
bones.  In  6  instances  it  was  a  railroad  crush,  in  4  a  fall  from  a 
height,  and  in  1  each  a  crush  under  a  bank  of  earth,  a  crush  in  an 
elevator  shaft,  and  a  crush  from  the  wheel  of  a  wagon  passing  over  the 
pelvis. 

It  is  seldom  that  the  fragments  become  much  displaced,  so  that 
perceptible  deformity  is  rarely  present;  but  unnatural  mobility  and 
crepitus  can  usually  be  elicited  by  manipulation,  to  which  are  added 
local  tenderness  and  wide-spreading  ecchymosis  as  symptoms  to  estab- 
lish the  diagnosis. 

The  importance  of  fractures  of  the  pelvic  bones  attaches  not  so 
much  to  the  injury  to  the  bones  themselves  as  to  possible  coincident 
injury  of  the  pelvic  viscera  or  blood-vessels,  or  to  the  existence  of 
other  serious  injuries  in  other  parts  of  the  body.  The  urinary  bladder 
and 'the  urethra  are  especially  liable  to  be  injured,  and  an  investigation 
of  their  condition  should  be  among  the  first  attentions  rendered  in  a 
case  of  pelvic  injury.     Contusion  of  some  portion  of  bowel  or  of  the 


SPECIAL   FRACTURES.  573 

kidney  is  a  frequent   complication ;  and  laceration   of  an  iliac  vein  or 
one  of  its  main  branches  may  occasion  fatal  internal  bleeding. 

The  acetabulum  may  be  the  seat  of  a  fracture  limited  to  its  own 
area  by  the  impact  of  the  head  of  the  femur.  Instances  are  reported 
in  literature  in  which,  as  the  result  of  a  fall  upon  the  great  trochanter, 
the  head  of  the  femur  has  perforated  the  dome  of  the  acetabulum,  even 
to  full  penetration  into  the  pelvic  cavity.  Such  an  accident  is  not  easily 
distinguishable  from  fracture  of  the  neck  of  the  femur,  except  in  case 
of  actual  intrapelvic  penetration,  when  a  rectal  exploration  of  the 
internal  lateral  wall  of  the  pelvis  will  reveal  the  presence  of  the  intrud- 
ing head  of  the  femur. 

The  rim  of  the  acetabulum  may  be  chipped  off,  to  a  greater  or  less  extent,  as  a  compli- 
cation of  a  dislocation  of  the  head  of  the  femur,  when,  in  the  production  of  the  displace- 
ment, the  head  of  the  bone  has  been  driven  with  great  force  against  the  containing  rim  of 
the  joint-cavity.  Such  an  accident  would  add  to  the  symptoms  of  dislocation  that  of  crepi- 
tus indicative  of  the  fracture,  together  with  a  tendency  to  redislocation  after  reduction.  The 
character  of  the  violence  required  for  its  production  is  so  extreme  that  other  and  more  impor- 
tant, usually  fatal,  injuries  are  likely  to  complicate  the  case,  so  that,  in  fact,  the  injury  to  the 
rim  of  the  acetabulum  has  but  little  more  than  a  pathological  interest. 

The  coccyx  may  be  fractured  by  falls,  kicks,  or  the  violent  impact  of  a  fetal  head  escap- 
ing through  a  narrow  inferior  strait.      Union  at  an  angle  is  likely  to  result. 

As  regards  the  after=COUrse  of  pelvic  fractures  in  general,  special  interest  attaches 
only  to  complicating  injuries.  The  little  tendency  to  displacement  of  the  fragments  and  the 
vascular  nature  of  the  bones  ensures  early  repair  with  firm  union. 

In  the  treatment  of  fracture  of  any  portion  of  the  pelvic  girdle 
proper,  it  is  required,  in  addition  to  the  dorsal  recumbent  position,  that 
the  pelvis  be  surrounded  by  a  broad,  snugly  drawn  bandage.  This 
support  should  be  maintained  for  four  weeks  or  more.  In  fractures 
limited  to  an  iliac  wing,  such  pelvic  bandage  should  be  omitted,  owing 
to  its  tendency  to  displace  the  fragment. 

The  Femur. — Fracture  of  the  femur  is  of  comparatively  frequent 
occurrence,  forming  about  6  per  cent,  of  all  fractures.  The  neck  and 
the  middle  third  of  the  shaft  are  most  frequently  broken.  Such  spe- 
cial conditions  attach  to  the  injuries  of  each  of  the  extremities  and  of 
the  shaft  as  to  necessitate  separate  consideration  of  each  of  those 
regions. 

The  upper  extremity  includes  the  head,  neck,  and  trochanters.  It 
may  be  broken  at  any  part  of  its  extent,  the  most  frequent  cause  being 
a  fall  upon  the  outer  side  of  the  hip.  Such  fracture  may  occur  at  any 
age,  but  is  by  far  the  most  frequent  in  old  people,  in  whom  the  strength 
of  the  femoral  neck  is  often  lessened  by  senile  osteoporosis.  This 
degeneration  of  the  cervical  substance  occasionally  becomes  so  great 
that  fracture  of  it  results  from  very  trivial  violence,  such  as  a  sudden 
twist  of  the  body,  a  trip,  a  misstep,  or  other  slight  force  applied  verti- 
cally by  impact  upon  the  foot  or  knee.  Fracture  thus  caused  is  at  the 
weakest  part  of  the  neck,  its  most  constricted  part,  immediately  behind 
the  head  and  within  the  capsule.  In  adolescents,  the  tearing  away  of 
the  upper  epiphysis  alone  is  conceivable  as  a  possibility  from  extreme 
violence.  In  one  recorded  case,  the  existence  of  the  injury  was  con- 
firmed by  autopsy. 

In  fractures  produced  by  a  direct  blow  upon  the  great  trochanter — 
that  is  to  say,  in  the  vast  majority  of  fractures  of  the  upper  extremity 
of  the  femur — there  is  always  at  first  more  or  less  impaction  of  the 


574 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


W                  y         I 

L                 '        m 

mm*f  0, 

I    *v 

^b.         "1 

b  1 

m8n** 

Fig.  267. —  Impacted  fracture  at  the  base  of  the  neck  of  the  femur.     Union  with  exuberant 

ossified  callus. 

fragments.     When  the  line  of  fracture  is  through  the  neck  and  chiefly 
within  the  capsule,  the  lower  and  posterior  wall  of  the  distal  fragment, 

as  a  rule,  is  driven  into  the  spongy 
/''       ""•»  '""'*•,         tissue  of  the  head,  which  is  driven 

\  downward  and  inclined  backward. 
When  the  fracture  is  at  the  base 
of  the  neck,  its  line  falling  mostly, 
if  not  entirely,  outside  the  capsule, 
the  acetabular  fragment  is  driven  into 
the  trochanteric  portion,  as  shown  in 
Fig.  267.  Again,  impaction  is  deep- 
est behind  and  below,  causing  the 
trochanter  major  to  be  turned  back- 
ward and  the  whole  limb  to  be 
everted.  Widely  varying  degrees 
of  impaction  and  comminution  will 
be  present  in  different  cases,  depend- 
ing upon  the  violence  of  the  force 
and  fragility  of  the  bone.  The  tro- 
chanter may  be  penetrated  with 
such  force  as  to  be  split  into  sev- 
eral fragments,  as  shown  in  the 
specimen  illustrated  in  Fig.  268. 
On  the  other  hand,  the  fracture  may 
be  incomplete — a  condition  more 
likely  to  be  met  with  in  young  sub- 
jects.      The    periosteum    investing 

chanteric  expansion,  comminution,  and  wide     this  portion  ofthe    femur  is  SO  thick- 

KS^^if!YSk).(M1,,,e,,moftlleM■    ened    and     strengthened    by    fibers 

reflected  from  the   capsule  and  the 
tendons  inserted  into  the  trochanter,  that  it  is  seldom  completely  torn 


FlG.   268. — Fracture   at  the   base   of  the 
neck  of  the  femur,  with  impaction  into  tro- 


SPECIAL    FRACTURES. 


575 


through  when  the  bone  is  fractured.  The  untorn  portion  serves  to 
hold  the  fragments  together,  and  may  be  an  important  source  of  vas- 
cular supply  to  the  proximal  fragment  when  the  line  of  fracture  is 
through  the  narrow  part  of  the  neck.  Later,  it  may  be  torn  com- 
pletely through  by  too  energetic  diagnostic  manipulations  of  the  bone 
or  by  too  early  attempts  at  walking,  or  it  may  become  gradually  elon- 
gated by  muscular  traction  while  softened  by  inflammatory  changes. 

The  normal  softening  of  the  bony  tissue  immediately  adjacent  to 
the  line  of  fracture,  which  is  the  first  stage  of  repair  in  all  bones,  is 
prone  to  become  exaggerated  in  fractures  through  the  narrow  part  of 
the  neck,  owing  to  the  antecedent  osteoporotic  degeneration  and  to 
the  limited  supply  of  blood  to  the  acetabular  fragment.  Gradual 
absorption  of  the  softened  tissue  is  prone  to 
occur,  and  in  some  instances  the  entire  neck 
disappears.  An  extreme  degree  of  this  dis- 
appearance of  the  neck  is  shown  in  Fig.  269. 
When  the  fracture  is  at  the  base  of  the  neck, 
however,  the  conditions  for  repair  are  re- 
versed, and  often  there  is  an  exuberance  of 
new-bone  production. 

Of  the  symptoms  attending  fracture  of  the 
neck  of  the  femur,  the  immediate  helpless- 
ness of  the  limb  which  follows  the  injury  is 
in  the  great  majority  of  cases  very  marked, 
although  in  exceptional  and  rare  instances 
the  ability  to  walk  has  not  been  absolutely 
lost.  Much  pain  is  usually  complained  of, 
especially  upon  any  attempt  at  rotation  or 
flexion  at  the  hip;  an  unnatural  fulness  may 
generally  be  noted  anteriorly  in  the  fold  of 
the  groin,  and  pressure  made  in  this  region   of  the  femur;  non-union,  absorp- 

.iv         ,.  1..1  ,     .  .    r   ,         S  tion  of  the  neck,  fragments  looselv 

in  the  direction  01  the  neck  is  painful.     Out-   connected  by  the  capsule, 
ward  rotation  of  the  whole  limb,  evidenced 

by  eversion  of  the  foot,  is  the  rule.  To  this  eversion  contribute  the 
greater  interpenetration  of  the  tissues  of  the  posterior  wall  of  the 
broken  neck,  the  strong  contraction  of  the  irritated  external  rotator 
muscles,  and  the  natural  weight  of  the  limb.  Inversion  of  the  foot 
has,  however,  been  reported  to  have  been  present  in  some  authenti- 
cated cases,  so  that  the  absence  of  eversion  does  not  absolutely  nega- 
tive the  existence  of  a  fracture  through  the  neck  of  the  femur.  The 
amount  of  shortening  immediately  following  the  injury  will  vary 
according  to  the  degree  of  impaction,  or,  in  the  absence  of  impaction, 
to  the  amount  of  laceration  of  the  capsule  and  the  periosteo-aponeu- 
rotic  investment  of  the  neck  and  the  consequent  longitudinal  displace- 
ment from  muscular  contraction.  A  slight  primary  shortening  due  to 
impaction  may  gradually  become  much  greater  through  the  interstitial 
absorption  of  the  neck,  and,  in  the  absence  of  impaction,  later  increase 
of  shortening  may  imperceptibly  develop  from  the  consecutive  stretch- 
ing of  the  fibrous  bands  which  connect  the  fragments.  Often  at  first 
there  is  no  appreciable  shortening,  or,  if  any  is  present,  it  is  limited  to 
a  fraction  of  an  inch.     After  some  weeks  or  months,  a  shortening1  of  2 


Fig.  269. — Fracture  of  the  neck 


57^  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

inches  or  more  may  be  found  to  be  present.  The  position  and  promi- 
nence of  the  great  trochanter  will  be  influenced  by  the  degree  of 
impaction,  shortening,  and  eversion  ;  being  less  prominent  and  lying 
above  its  natural  position,  according  as  the  axis  of  the  neck  is  short- 
ened and  depressed.  When  it  has  been  split  and  its  fragments  sepa- 
rated by  the  wedge-like  action  of  the  neck  driven  into  it,  the  massive 
callus  which  invests  it  can  often  be  plainly  felt  by  palpation.  Crepitus 
is  seldom  easily  elicited ;  usually  it  is  prevented  by  the  existing  impac- 
tion, and,  in  the  absence  of  impaction,  is  still  interfered  with  by  the 
mobility  of  the  acetabular  fragment. 

The  diagnosis  of  fracture  of  the  neck  of  the  femur  is  usually  attended 
with  little  difficulty  or  uncertainty.  The  assemblage  of  symptoms  is 
characteristic;  a  history  of  a  fall  upon  the  hip,  or  of  disability  suddenly 
induced  in  an  aged  person  by  a  slight  strain  or  concussion  confirms  the 
diagnosis.  Severe  contusion  without  fracture  may  cause  symptoms 
which  at  first  closely  simulate  those  due  to  fracture.  In  case  of  doubt, 
the  more  serious  condition  should  be  considered  as  present,  until  the 
rapid  subsidence  of  tenderness  and  helplessness  has  demonstrated  the 
real  nature  of  the  accident.  Much  uncertainty  will  frequently  exist  as 
to  the  exact  point  along  the  neck  at  which  the  fracture  has  occurred, 
and  especially  as  to  the  relations  of  the  line  of  fracture  to  the  insertion 
of  the  capsule.  As  this  point  is  of  importance  only  in  the  prognosis 
of  the  case,  no  extended  and  violent  manipulations  for  the  purpose  of 
determining  it  are  justifiable,  in  view  of  the  possibility  of  thereby  break- 
ing up  impaction  or  lacerating  periosteal  and  capsular  bands  that  may 
still  connect  the  fragments.  No  manipulations  that  cannot  readily  be 
born  by  the  patient  without  an  anesthetic  should  ever  be  made,  and 
even  these  should  be  made  with  particular  care  and  gentleness. 

In  the  case  of  young  children,  the  symptoms  caused  by  fracture  of  the  neck  of  the  femur 
may  possibly  be  mistaken  for  those  of  coxitis,  especially  since  the  fracture  is  likely  to  be  an 
incomplete  one,  attended  with  bending  of  the  neck  without  actual  separation  of  the  frag- 
ments, and  the  ability  to  walk  with  a  limp  is  regained  in  a  short  time  ;  besides,  the  possi- 
bility of  fracture  of  the  neck  of  the  femur  in  young  children  is  not  generally  recognized. 
The  immediate  supervention  of  the  characteristic  symptoms  of  helplessness,  pain,  muscular 
spasm,  deformity,  and  eversion  of  the  limb  after  an  injury  to  the  hip  in  the  case  of  a  child 
should  be  sufficient  to  differentiate  it  from  the  slow  and  irregular  onset  of  tuberculous  coxitis. 

The  prognosis  will  be  affected  by  the  age  of  the  patient,  the  proxim- 
ity of  the  seat  of  the  fracture  to  the  head  of  the  bone,  and  the  presence 
or  absence  of  impaction.  Some  permanent  impairment  of  the  functions 
of  the  limb  is  in  all  cases  to  be  expected,  even  in  those  that  pursue  the 
most  favorable  course.  This  may  vary  from  a  slight  limp  to  total  help- 
lessness of  the  limb.  Death  within  a  few  days  is  not  uncommon  in 
aged  persons,  from  the  effects  of  the  shock  and  the  local  inflammatory 
reaction  ;  death  frequently  follows,  also,  after  some  weeks  or  months 
from  renal  and  pulmonary  complications,  induced  or  aggravated  by  the 
confinement  or  suffering  incident  to  the  injury,  from  exhaustion  due  to 
decubitus,  or  from  the  supervention  of  suppuration  about  the  fracture. 
Non-union,  usually  without  any  intervening  material  connecting  the  two 
fragments,  sometimes  with  strong  fibrous  adhesions,  is  the  usual  result 
of  fractures  through  the  narrow  part  of  the  neck.  To  this  contributes 
not  only  the  absorption  of  the  neck,  noted  in  a  previous  paragraph,  but 
also  the  impossibility  in  many  cases  of  securing  accurate  coaptation  and 


SPE  CIA  L    FKA  CTURES. 


577 


prolonged  immobilization  of  the  fragments,  owing  to  the  serious  effect 
upon  the  general  condition  of  the  patient  produced  by  the  confinement 
required,  which  often  early  compels  the  total  abandonment  of  all  efforts 
at  retention  and  immobilization.  The  possibility  of  bony  union  occur- 
ring after  a  fracture  of  that  part  of  the  neck  within  the  capsule  has  been 
denied  by  many.  That  it  is  very  rare  is  certain ;  but  it  is  reasonable  to 
grant  that,  in  exceptional  cases,  a  firm  impaction  of  the  fragments  and 
the  presence  of  a  broad  strip  of  untorn  periosteum  may  secure  sufficient 
fixation  and  nutrition  to  the  acetabular  fragment  to  ensure  bony  union 
ultimately.  The  repair  will  be  slow,  and  may  be  arrested  by  too  early 
attempts  at  use  of  the  limb.  The  use  of  retentive  apparatus  should  be 
persevered  in  for  a  period  of  not  less  than  ninety  days,  whenever  there 
is  any  reason  to  hope  for  bony  union.  Fractures  at  the  base  of  the 
neck  unite  by  bony  union,  if  apposition  and  immobilization  are  main- 
tained. The  certainty  and  rapidity  of  their  repair  are  frequently  favored, 
and  their  treatment  is  often  greatly  facilitated,  by  the  presence  of  deep 
and  firm  impaction.  The  possibility  of  consecutive  shortening  from 
absorption  of  the  neck  has  been  described  in  a  previous  paragraph.  In 
children,  a  gradual  increase  of  shortening  and  deformity  during  adoles- 
cence, from  further  descent  of  the  depressed  neck,  may  be  expected. 

Treatment. — In  all  cases,  efforts  to  bring  the  fragments  into  apposi- 
tion and  to  immobilize  them  should  be  at  once  inaugurated. 

The  existence  of  impaction  is  of  the  utmost  importance  in  facili- 
tating treatment,  and  every  effort  should  be  made 
during  the  preliminary  care  and  examinations  to 
preserve  it  when  present,  the  patient  being  placed 
upon  a  firm  hair-mattress.  Lateral  pressure  and 
support  should  be  given  to  the  injured  hip  by  a 
stout  pelvic  bandage  drawn  snugly ;  this  may  be 
reinforced  by  a  sand-bag  applied  under  the  tro- 
chanter so  as  to  support  it' and  prevent  further  ten- 
dency to  eversion  ;  the  foot  should  be  protected 
from  the  weight  of  the  bed-clothing  by  a  suitable 
cage.  Additional  fixation  may  best  be  secured  by 
moulding  to  the  posterior  aspect  of  the  limb  and 
body  a  bar  of  soft  iron,  f  inch  in  thickness  and  \\ 
inches  wide,  long  enough  to  reach  from  the  axilla 
to  the  lower  fourth  of  the  leg.  To  this  should  be 
united  a  transverse  band  of  lighter  material  at  each 
end,  the  upper  one  long  enough  nearly  to  embrace 
the  thorax,  the  lower  one  the  ankle.  A  third  trans- 
verse band  is  added  at  a  point  so  that  it  shall 
embrace  the  thigh  just  below  the  perineal  crease. 
This  apparatus  is  secured  in  place  by  proper  band- 
aging, as  shown  in  Fig.  270.  This  will  be  recog- 
nized as  the  splint  devised  by  Thomas  for  the  treat- 
ment of  hip-joint  affections.  Various  modifications 
of  it  may  be  required  to  suit  it  to  the  peculiarities 
of  individual  cases.  Weight  extension  may  be 
added,  if  necessary  to  control  tendency  to  shorten- 
ing.    This  apparatus  secures  fixation  quite  satisfactorily,  while  it  greatly 


Fig. 


270. — The  Thomas 
hip-splint. 


5/8 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


facilitates  the  nursing  required  by  the  patient.  After  it  has  been  applied, 
the  patient  may  be  lifted  or  turned  upon  the  sound  side,  and,  still  wear- 
ing the  splint,  maybe  got  out  of  bed  upon  crutches  some  weeks  earlier 
than  would  otherwise  be  prudent.  The  splint  maybe  discarded  entirely 
at  the  end  of  from  twelve  to  sixteen  weeks. 

Another  method  is  to  apply  a  long  wooden  side-splint  extending 
from  ankle  to  axilla,  with  or  without  extension,  according  to  the  ten- 
dency to  shortening. 

Whenever  there  appear  evidences  of  serious  impairment  of  health, 
due  to  attempts  at  immobilization,  they  must  be  abandoned,  and  the 
general  condition  of  the  patient  attended  to. 

The  shaft  of  the  femur  may  present  any  variety  of  fracture  to  which 
a  long  bone  is  liable,  whether  from  direct  or  indirect  violence  or  from 
the  contraction  of  its  own  muscles.  The  line  of  fracture  is  usually 
oblique,  as  shown  in  Fig.  271  ;  but  transverse  fracture  is  not  uncommon, 
especially  in  children,  in  whom  also  the  preservation  untorn  of  a  part 
of  the  periosteal  investment  of  the  fractured  region  is  frequent.  Nota- 
ble displacement,  longitudinal,  angular,  and  rotary,  usually  attends 
fracture  of  the  shaft.  This  is  due  both  to  the  primary  fracturing  force 
and  to  the  subsequent  action  of  the  powerful  muscles   of  the  thigh. 


Fig.  271. — Common  form  of  fracture  of  the 
shaft  of  the  femur  (Hoffa). 


Fig.  272. — Diagram  illustrating  direction 
of  chief  lines  of  muscular  contraction,  with 
tendency  to  displacement  resulting  after 
fracture  of  upper  third  of  the  femur. 


This  tendency  to  displacement  assumes  especial  importance  from  its 
bearing  on  the  progress  of  repair  and  upon  the  possibilities  of  perma- 
nent deformity  and  lameness.  Obliquity  of  the  fracture,  generally 
present,  favors  the  slipping  of  the  fragments  by  each  other,  the  tendency 
to  which  is  inevitable,  from  contraction  of  the  parallel  muscular  masses 
which  invest  the  bone.     The  lower  fragment  is  usually  drawn  to  the 


SPECIAL   FRACTURES.  579 

inner  side  and  behind  the  upper,  with  the  formation  of  a  more  or  less 
well-marked  angular  deformity,  the  projection  of  which  is  often  visible 
on  the  anterior  and  outer  aspect  of  the  thigh.  The  tendency  to  this 
angular  deformity  is  more  apt  to  be  great  in  fractures  of  the  upper  third 
of  the  shaft,  in  which,  in  addition  to  the  action  of  the  peroneotibiopelvic 
muscles  upon  the  lower  fragment,  the  upper  fragment  is  prone  to  be 
tilted  upward  by  the  action  of  the  iliotrochanteric  muscles  (Fig.  272). 
The  effect  of  muscular  contraction  may,  however,  be  much  limited  by 
the  strength  of  the  tendinous  and  aponeurotic  investments  remaining 
untorn  about  the  seat  of  the  fracture. 

Tendencies  to  outward  rotary  displacement  of  the  upper  fragment 
from  the  uncontrolled  action  of  the  external  rotators  inserted  into  the 
great  trochanter,  and  of  the  lower  fragment  from  the  natural  tendency 
from  gravity  of  the  foot  to  fall  upon  its  outer  side,  also  characterize 
these  injuries. 

The  diagnosis  of  fracture  of  the  shaft  of  the  femur  is  usually  with- 
out question  upon  simple  inspection  and  manipulation  of  the  limb,  by 
which  the  classical  signs  of  fracture  are  at  once  appreciated.  The 
thickness  of  the  overlying  soft  tissues,  however,  prevents,  in  most  cases, 
the  accurate  recognition  of  the  details  of  the  line  of  fracture  and  of  the 
displacement.  More  exact  knowledge  may  be  obtained  by  the  freer 
manipulation  which  general  anesthesia  would  make  possible ;  but  the 
use  of  such  extended  manipulations  should  rarely  be  resorted  to,  on 
account  of  the  increased  damage  to  the  surrounding  soft  tissues, 
which  they  produce.  An  A^-ray  skiagraph,  when  procurable,  is  of 
especial  value  in  demonstrating  the  exact  relation  of  the  fragments. 
Comparative  measurement  of  the  length  of  the  two  limbs  is  of 
great  value  for  ascertaining  the  longitudinal  displacement.  It  should 
be  frequently  done  during  the  first  weeks  of  treatment,  for  the  pur- 
pose of  controlling  the  extending  force  to  be  used.  When  meas- 
urements are  taken,  it  is  important,  in  order  to  render  them  exact  for 
purposes  of  comparison,  that  the  patient  should  lie  upon  a  flat,  firm 
surface,  that  the  pelvis  should  not  be  tilted  in  any  direction,  and  that 
the  longitudinal  axis  of  each  limb  should  make  the  same  angle  with 
the  transverse  axis  of  the  pelvis. 

One  end  of  the  measuring  tape  should  then  be  firmly  pressed  against 
the  lower  surface  of  the  projecting  anterior  spine  of  the  ilium  above, 
while  the  lower  end  is  carried  to  the  lower  edge  of  the  internal  malleo- 
lus at  the  ankle.  Great  care  and  repeated  comparison  of  measure- 
ments are  required  to  avoid  errors  due  to  the  readiness  with  which  the 
soft  tissues  covering  the  prominences  named  glide  under  pressure. 

Prognosis. — This  injury  is  always  a  serious  accident,  requiring,  under 
usual  methods  of  treatment,  confinement  to  bed  for  weeks,  entailing 
considerable  disability  and  lameness  for  months,  and,  in  some  cases, 
such  shortening  as  to  cause  permanently  a  limping  gait.  Usually,  in 
adults,  a  simple  fracture  of  the  shaft  of  the  femur,  intelligently  treated, 
will  by  the  end  of  eight  weeks  consolidate  with  sufficient  firmness  to 
make  it  prudent  for  the  patient  to  be  allowed  out  of  bed  on  crutches, 
which  after  four  weeks  more  may  be  discarded  altogether.  While  the 
possibility  of  union  without  shortening  in  especially  favorable  cases 
(such  as  transverse  fractures  and  fractures  in  children)  is  undeniable, 


580 


INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 


still,  no  special  method  of  treatment  can  be  depended  on  to  ensure  it  in 
any  given  case.  The  normal  asymmetry  of  the  two  limbs  is  not  to  be 
overlooked  in  estimating  the  results  of  treatment,  for  a  normally  longer 
limb  will  possibly  still  be  as  long  as  the  opposite  one,  notwithstanding 
considerable  shortening ;  or,  on  the  contrary,  a  normally  shorter  limb 
may,  after  consolidation,  present  apparently  marked  shortening,  when 
the  amount  of  shortening  due  to  the  injury  has  actually  been  slight. 
Exact  apposition  of  the  fractured  surfaces  can  rarely  be  secured,  nor 
can  some  overriding  of  the  fragments  be  prevented,  however  intelligent 
and  assiduous  the  care.     A  result  is  to  be  accepted  as  good  when  bony 


Fig.  273. — Fracture  at  the  middle  of  the  shaft  of  the  femur.     Union  with  shortening  and 
external  angular  deformity  (Warren  Museum,  Boston). 

union  has  been  secured  with  no  perceptible  angular  deformity,  when 
the  normal  outward  inclination  of  the  foot  has  been  preserved,  and 
when  the  shortening  of  the  limb  does  not  exceed  an  inch.  In  the 
majority  of  cases,  this  should  not  be  more  than  \  inch  in  amount.  The 
lapse  of  some  time — at  least  one  year — is  necessary  before  final  judg- 
ment can  be  formed  as  to  the  perfection  of  functional  recovery. 

Treatment. — The  recumbent  position,  with  some  form  of  continuous 
extension,  combined  with  apparatus  for  the  immobilization  of  the  frag- 
ments, is  requisite.  A  proper  bed  is  important.  It  should  be  narrow, 
preferably  36  inches  in  width.  The  mattress  should  be  of  hair,  firmly 
made,  not  more  than  4  inches  thick,  and  should  be  placed  upon  an 
even,  unyielding  surface,  best  and  most  conveniently  secured  by  placing 
underneath  the  mattress,  between  it  and  the  springs  which  usually 
support  it,  a  layer,  an  inch  thick,  of  matched  boards,  like  those  of  a 
door.  Thus  the  nates  are  prevented  from  sinking  down  into  the 
mattress,  and  the  necessary  care  for  the  reception  and  removal  of 
excretions  is  facilitated.  Decubitus  is  to  be  prevented  by  the  use  of 
pillows  and  pads,  as  required  to  shift  pressure  and  promote  comfort. 
Holes  in  the  mattress  or  special  apparatus  for  raising  the  patient  are 
rarely,  if  ever,  necessary.  Sufficient  access  to  the  urethra  and  the 
rectum  can  be  had  by  raising  the  sound  thigh. 

Extension  is  best  secured  by  the  continuous  traction  of  a  weight 
(a  bag  of  shot  or  sand,  etc.)  fastened  to  a  cord  which,  passing  over  a 
pulley  attached  to  the  foot  of  the  bedstead,  is  fastened  to  strips  of 
adhesive  plaster  which  have  been  applied  to  either  side  of  the  injured 
limb  from  the  ankle  up  to  the  point  of  fracture.  Fig.  274  shows  the 
method  of  applying  these  strips.     They  should  extend  upward  above 


SPECIAL   FRACTURES. 


58l 


the  knee,  along  the  thigh  to  a  point  a  little  above  the  level  of  the  fract- 
ure. The  complete  apparatus  is  shown  in  Fig.  276.  For  the  purpose 
of  lessening  the  resistance  to  extension  caused  by  the  burrowing  of 
the  foot  and  leg  into  the  mattress,  they  should  be  lifted  from  the 
surface  of  the  mattress  and  supported  upon  the  sliding  apparatus 
shown  in   Fig.   275   (Volkmann's   sliding  rest)  and  also   in   Fig.   276. 


Fig.  274. — Application  of  adhesive  strips  for  making  continuous  weight-extension  of  leg  and 
thigh  :  a,  the  adhesive  plaster  shaped  and  applied ;  b,  the  retaining  roller  bandage  applied,  and 
the  apparatus  ready  for  attachment  of  the  weight. 

Sufficient  counterextension  is  obtained  from  the  weight  of  the  body, 
aided  by  elevating  the  foot  of  the  mattress-board,  or  of  the  bedstead 
if  preferred,  to  the  extent  of  6  or  more  inches.  This  extension  appa- 
ratus should  be  applied  as  soon  after  the  accident  as  possible.  By  the 
continuous  tension  of  a  moderate  weight-traction  thus  exerted,  the 
inevitable  spasm  of  the  thigh  muscles  is  gradually  overcome,  and  the 
overriding  of  the  fragments   is   corrected.     A  weight  of    10  pounds 


FIG.  275. — Sliding  foot-piece  (after  Volkmann). 


should  be  attached  at  first  in  the  case  of  an  adult,  this  being  increased 
from  day  to  day,  as  found  necessary,  until  measurements  show  the 
injured  limb  to  be  of  equal  length  with  its  fellow.  About  the  fifth 
week  the  weight  may  be  discarded.  At  the  same  time  the  whole  limb 
should  be  steadied  by  a  posterior  splint  reaching  from  the  gluteal 
crease  above  to  the   lower  edge  of  the  calf  below.     Liberal  padding 


582 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


should  be  placed  under  the  knee,  so  as  to  flex  it  slightly,  and  thus  pre- 
vent the  painful  hyperextension  of  the  knee-ligaments  otherwise 
caused  by  the  weight-traction.  The  roller  bandage  by  which  this 
posterior  splint  is  fixed  to  the  limb,  applied  with  moderate  firmness 
below  the  knee,  should  be  sufficiently  loose  along  the  thigh  to  accom- 
modate later  swelling.  For  the  immobilization  of  the  fracture  chief 
reliance  is  to  be  placed  upon  a  long  external  splint  reaching  from  the 
axilla  above  to  beyond  the  sole  of  the  foot  below.  The  application 
of  this  splint  is  shown  in   Fig.  276. 

The  lower  end  of  this  splint  passes  through  the  slot  shown  in  the 
footpiece  of  the  sliding  rest,  and  thereby  full  control  of  any  tendency 


FlG.  276. — Complete  permanent  dressing  for  fracture  of  shaft  of  the  femur. 


to  outward  rotation  of  the  foot  is  secured,  for  by  tilting  the  transverse 
pieces  which  support  the  tramway  along  which  this  foot-rest  slides,  any 
lateral  inclination  desired  can  be  given  to  the  foot. 

At  the  expiration  of  a  week,  the  tendency  to  shortening  having 
been  overcome,  and  the  primary  swelling  of  the  thigh  having  begun  to 
subside,  short  coaptation  splints  may  be  added  to  the  internal  and 
anterior  surfaces  of  the  thigh.  The  retention  of  the  limb  in  its  splints 
will  be  required  for  a  period  of  from  eight  to  ten  weeks  before  suffi- 
ciently firm  consolidation  will  have  occurred  to  make  it  prudent  to 
dispense  with  them  and  get  the  patient  up  on  crutches.  Should,  how- 
ever, any  reason  arise  making  it  important  to  get  the  patient  out  of 
bed  at  an  earlier  date,  or  should  delay  in  consolidation  indicate  need 
for  the  stimulus  of  locomotion  and  the  upright  position,  and  relief  from 
tedious  confinement,  sufficient  support  to  the  fracture  may  be  obtained 
by  encasing  the  limb  and  pelvis  in  plaster- of-Paris  bandage,  or  by  the 
application  of  the  iron  hip-splint  of  Thomas  (Fig.  277),  or  some  form 
of  the  traction-braces  used  in  the  treatment  of  hip  disease.  In  chil- 
dren, on  account  of  their  restlessness  and  the  special  attentions  needed 
to  keep  the  dressings  free  from  urine  and  feces,  vertical  suspension  of 
the  limb  (Fig.  278)  may  with  advantage  be  substituted  for  the  longi- 
tudinal extension  used  for  older  patients. 


SPECIAL    FRACTURES. 


;S3 


In    some    cases    of  fracture   through    the    upper    third    of    the 

shaft,  the  tendency  to  displacement  may  be  so  great  that  it  cannot 

be  overcome  until  the  thigh-muscles  are  relaxed  by  moderate  flexion 

of  the  thigh  upon  the  pelvis  and  of  the  leg  upon  the  thigh.     This  can 

be    accomplished    by    placing    the 

limb  upon  a  double  inclined  plane 

(Fig.   279).      Traction  in  the  long 

axis  of  the  femur  may  be  obtained 

by  applying  the  adhesive  straps  to 

the  thigh  only,  and   elevating  the 

pulley  at  the  foot  of  the  bed. 

The  lower  third  of  the  femur 
may  be  broken  by  direct  violence, 
or  by  such  indirect  force  as  a  fall 
upon  the  feet  or  knee,  or  a  propul- 
sion forward  of  the  body  with  the 
knee  held  in  hyperextension,  or  by 
a  combination  of  torsion  and  trac- 
tion. Fractures  in  this  portion  of 
the  bone  have  an  especial  gravity 
on  account  of  the  proximity  of 
the  knee-joint,  the  possibility  of 
the  popliteal  blood-vessels  being 
compressed  or  lacerated,  and  the 
tendency  to  excessive  blood-extrav- 
asation from  the  torn  vessels  of  the 
vascular  bone  and  the  investing  peri- 
osteum. 

The  line  of  fracture  may  be 
more  or  less  transverse  from  side 
to  side,  with  anteroposterior  obliq- 
uity, or  may  run  obliquely,  de- 
taching a  condyle  and  entering  into 
the  knee-joint.  There  may  be  much 
comminution,  with  or  without  impac- 
tion of  fragments.  In  childhood  and 
youth,  the  lower  epiphysis  alone 
may  be  torn  away — an  accident 
which,  in  the  majority  of  reported  cases,  has  been  caused  by  entangle- 
ment of  the  leg  in  a  revolving  wheel.  The  displacement  depends 
chiefly  upon  the  direction  of  the  fracturing  force  and  the  lines  of 
obliquity  presented  by  the  fragments.  In  supracondyloid  fractures, 
the  line  of  fracture  is  often  oblique,  from  behind  downward  and  for- 
ward, with  protrusion  of  the  lower  end  of  the  upper  fragment  forward 
and  downward  toward  the  patella  (Fig.  280) ;  but  displacement  of  an 
opposite  character  is  not  infrequent.  When  with  the  first-mentioned 
displacement  the  line  of  fracture  is  above  the  insertion  of  the  gastroc- 
nemii  muscles,  the  lower  fragment  may,  in  exceptional  instances,  become 
so  strongly  flexed  by  the  contraction  of  these  muscles  that  the  fract- 
ured surface  projects  backward  into  the  popliteal  space,  and  great, 
sometimes  insuperable,  difficulties  may  attend  efforts  to  secure  proper 


Fig.  277. — Thomas's  hip-splint  used  as 
an  ambulatory  appliance  in  a  case  of  fract- 
ure of  the  shaft  of  the  femur  with  delayed 
union. 


584 


INTERNATIONAL    TEXT-BOOK   OE  SURGERY. 


adjustment  of  the  fragments.  In  epiphyseal  separations,  the  line  of 
fracture  is  just  below  the  origin  of  this  calf-muscle,  and  in  the  majority 
of  reported  cases  the  epiphysis  has  been  dislocated  forward,  retaining 
its  normal  relations  to  the  knee-joint  and  the  tibia,  while  the  lower  end 


FIG.  278. — Method  of  applying  vertical  suspension  of  the  limb  in  the  treatment  of  fracture 

of  the  femur  in  a  child. 

of  the  diaphysis  has  projected  backward  and  downward  into  the  poplit- 
eal space  (see  Fig.  281). 

Contraction  of  the  gastrocnemius,  attached  to  this  fragment,  inten- 
sifies the  displacement  and  resists  attempts  at  reduction.     In  a  number 


Fig.  279. — Double  inclined  plane  for  fracture  of  the  upper  third  of  the  shaft  of  the  femur. 

of  reported  cases  the  popliteal  vessels  have  been  lacerated  by  the  sharp 
edge  of  the  displaced  fragment,  or  have  been  so  compressed  by  it  as  to 
produce  gangrene  of  the  parts  distal  to  it.  In  the  treatment,  accurate 
reduction,  under  general  anesthesia,  is  of  primary  importance.     Relaxa- 


SPECIAL    FRACTURES. 


585 


tion  of  muscles  by  flexion  of  the  leg  upon  the  thigh  and  of  the  pelvis 
should  be  first  secured.  While  the  parts  are  kept  in  this  position,  the 
reduction  is  to  be  effected  by  manipulation  and  extension.  In  many 
instances  retention  of  the  fragments  in  position  after  reduction  may 
best  be  maintained  by  keeping  the  leg  flexed  for  a  time  upon  the  thigh, 
at  an  angle  as  acute  as  can  be  borne  with  comfort  by  the  patient,  the 
fixation  being  effected  by  suitable  bandaging,  while  the  limb  as  a  whole 
is  supported  upon  pillows  or  is  slung  in  a  hammock. 

Any  tendency  to  shortening  is  prevented  by  the  breadth  of  the  fract- 
ured surfaces  and  the  interlocking  of  their  irregularities  after  reduction 


FlG.  280. — Fracture  through  the  lower 
third  of  the  femur  healed  in  deformity  ; 
displacement  of  the  lower  end  of  the 
upper  fragment  downward  and  forward 
(Holthouse). 


FlG.  281. — Diagram  showing  usual  dis- 
placement after  separation  of  the  lower 
epiphysis  of  the  femur  (Robson). 


has  been  effected  ;  while  muscular  contraction  is  largely  antagonized  by 
the  position.  In  exceptional  cases  it  may  be  well  to  put  the  calf-mus- 
cles still  further  at  rest  by  section  of  the  tendo  Achillis.  Plaster-of- 
Paris  bandages  may  be  used  to  advantage  in  some  instances.  By  the 
third  week,  the  angle  of  flexion  may  be  reduced  a  half,  and  soon  there- 
after a  straight  position  will  be  possible,  without  disturbing  the  apposi- 
tion of  the  fragments.  In  many  cases,  after  reduction,  the  straight 
position,  with  or  without  weight-extension,  as  the  presence  or  absence 
of  tendency  to  shortening  may  indicate,  may  be  employed  from  the 
first.  Wound  of  either  of  the  great  popliteal  vessels  calls  for  exposure 
of  the  injured  point  by  free  incision  and  ligation,  with  either  amputation 
at  once  or  its  postponement  until  the  possible  failure  of  conservative 
measures  shall  have  unmistakably  declared  its  necessity.  If  the  knee- 
joint  has  been  penetrated,  either  by  the  primary  line  of  fracture  or  by 


586 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


a  sharp  spicule  of  the  displaced  upper  fragment,  it  may  become  greatly 
swollen  by  blood-extravasation.  If  absolute  asepsis  is  obtainable,  this 
may  be  evacuated  by  aspiration  or  incision  ;  otherwise,  its  removal  must 
be    left  to   absorption,   aided    by   massage   and   bandage-compression. 


Fig.  282. — Transverse  fract- 
ure of  the  patella. 


Fig.      283. —  Comminuted 
fracture  of  the  patella. 


Fig.   284. — Vertical  fracture 
of  the  patella. 


Long-continued   stiffness  of  the  joint  and,  in  some  cases,  permanent 
ankylosis  remain,  whatever  the  treatment. 

The  Patella. — Fracture  of  the  patella  is  usually  the  result  of  cross- 
breaking  strain  exerted  upon  the  bone  by  the  contraction  of  the  quadri- 
ceps femoris,  when  in  flexion  of  the  knee  the  patella  is  only  partially 
supported  by  the  convexity  of  the  condyles.  Often  direct  violence 
combines  with  muscular  action  to  effect  the  fracture,  as  in  a  fall  or  blow 


Fig.  285. — Fracture  of  the  patella,  showing  defective  apposition  of  fracture-surfaces  even  where 
fragments  are  brought  into  contact  by  manipulation  through  overlying  soft  parts  (Warren). 

upon  the  bent  knee.     In  very  exceptional  instances,  fracture  is  caused 
by  direct  violence  alone. 

The  line  of  fracture,  as  a  rule,  is  transverse  or  slightly  oblique,  being 


SPECIAL    FRACTURES. 


587 


seated  at  or  just  below  the  middle  of  the  bone.  Stellate  or  vertical 
lines  of  fracture  occur  as  the  result  of  direct  violence  (Figs.  282— 
284).  The  overlying  fibrous  coverings  of  the  bone  are  stretched  and 
irregularly  torn,  and  the  tear  extends  laterally  to  a  varying  degree,  in 
different  cases,  into  the  aponeurotic  capsule  of  the  knee-joint.  The 
degree  to  which  the  upper  fragment  is  retracted  depends  upon  the 
extent  of  laceration  of  these  fibrous  investments  ;  usually  the  separa- 
tion does  not  exceed  an  inch  in  extent,  but  occasionally  it  amounts  to 
3  or  more  inches.  In  fracture  by  direct  violence  alone,  the  fibrous 
investments  may  be  but  slightly  torn,  and  no  appreciable  separation  of 
the  fragments  may  result.  Tilting  of  the  fragments,  so  that  their  frac- 
tured surfaces  no  longer  face  each  other,  is  frequent  (Fig.  285).  The 
fractured  surface  of  the  upper  fragment  is  prone  to  be  turned  in 
toward  the  cavity  of  the  knee-joint  by  the  action  of  the  vasti  fibers 


Fig.  286. — Transverse  fracture  of  the  patella ; 
fractured  surface  partially  covered  by  irregular  flaps 
of  torn  aponeurosis  (Hoffa). 


Fig.  287. — Fibrous  band  of 
union  after  fracture  of  the  patella 
(Hoffa). 


inserted  into  its  sides,  while  the  distal  fragment  may  be  tilted  forward 
by  fluid  effused  into  the  joint. 

Into  the  gap  between  the  fragments  the  prepatellar  tissues  fall,  and 
a  fringe  or  apron,  composed  of  shreds  of  the  stretched,  lacerated, 
fibrous  covering  of  the  patella,  in  many  cases  invests  much  of  the 
fractured  surface,  more  especially  of  the  proximal  fragment  (Fig.  286). 
The  defective  apposition  of  the  fractured  surfaces  and  the  presence 
between  the  fragments  of  so  much  fibrous  tissue  is  sufficient,  as  a  rule, 
to  prevent  bony  union,  however  carefully  the  part  is  immobilized  and 
retraction  of  the  upper  fragment  prevented.  As  exceptions  to  this 
rule  stand  only  some  fractures  by  direct  force  in  which  neither  exten- 
sive laceration  of  the  fibrous  investments  nor  much  separation  of  the 
fragments  has  occurred. 


5' 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


The  fibrous  band  uniting  the  fragments  (Fig.  287)  does  not  exceed 
\  inch  in  length  in  most  favorable  cases,  and  the  functions  of  the  limb 
may  not  be  noticeably  impaired.  Gradual  elongation  of  the  uniting 
medium  is,  however,  of  frequent  occurrence,  so  that  the  distance 
between  the  fragments,  which  upon  the  removal  of  apparatus  was 
scarcely  \  inch,  may  be  found  after  some  months  to  have  become 
several  inches.  Complete  rupture  of  the  band  has  been  frequently 
recorded. 

Wide  separation  of  the  fragments  is  not  incompatible  with  usefulness 
of  the  limb,  whenever  that  portion  of  the  aponeurosis  of  the  vasti  mus- 
cles which  is  inserted  into  the  sides  of  the  lower  fragment  has  remained 
intact.  Marked  rigidity  of  the  knee-joint  persists,  as  a  rule,  for  some 
time  after  the  removal  of  apparatus,  due  to  the  peri-articular  contract- 
ures and  adhesions  following  the  inflammatory  and  hemorrhagic  infil- 
trations of  the  soft  tissues  and  the  long  disuse  of  the  joint.  This 
gradually  diminishes  under  ordinary  use,  but  in  most  cases  some 
diminution  of  range  of  flexion  and  loss  of  power  of  active  extension 
persist  throughout  life.     Occasionally  the  knee  remains  quite  stiff. 

The  symptoms  of  fracture  of  the  patella  are  at  once  recognizable  by 
sight  and  touch ;  the  division  of  the  bone  into  fragments  more  or  less 
widely  separated  and  capable  of  individual  mobility  declares  unmis- 
takably the  nature  of  the  accident.  The  loss  of  power  is  usually,  but 
not  necessarily,  at  once  complete ;  it  is  dependent  in  some  measure 
upon  the  extent  of  the  laceration  of  the  lateral  aponeuroses.  Disten- 
tion of  the  knee-joint  supervenes  rapidly  from  the  accumulation  of 
blood  and  serum  within  its  cavity,  and  extensive  ecchymosis  of  the 
adjacent  connective  tissue  quickly  follows. 

Treatment. — The  knee-joint  should  be  immobilized  by  a  suitable 
splint  adjusted  to  the  back  of  the  limb,  while  the  foot  is  elevated  upon 
a  pillow  (Fig.  288).  An  ice-bag  or  an  evaporating  lotion  should  be 
applied  to  the  knee  to  check  effusion  and  limit  inflammatory  reaction. 


FlG.  288. — Showing  back  splint  and  elevation  of  foot  advised  for  fractured  patella 

(Hamilton). 


After  the  third  day  these  may  be  omitted,  and  the  absorption  of  effu- 
sion promoted  by  the  elastic  pressure  of  a  flannel  roller  bandage, 
aided  by  massage.  Retraction  of  the  upper  fragment  is  to  be  con- 
trolled by  adjusting  a  shield  of  adhesive  plaster  to  the  front  of  the 
thigh,  so  that  the  lower  edge  of  the  plaster,  when  drawn  upon,  shall 
encompass  the  upper  edge  of  the  patella.     To  the  lower  lateral  angles 


SPECIAL    FRACTURES.  589 

of  this  shield  strong  elastic  bands  are  fastened,  which  are  attached 
below  to  the  under  surface  of  the  splint  at  the  ankle,  and,  drawn  tense, 
may  exert  a  constant  downward  pressure  upon  the  fragment.  The 
subsidence  of  the  swelling  and  the  tendency  of  the  superficial  tissues 
to  glide  make  frequent  readjustment  of  this  apparatus  necessary. 

The  permanent  splint  to  be  worn  during  immobilization  is  best 
made  from  several  layers  of  canton  flannel  or  towelling  saturated 
with  plaster-of-Paris  cream,  secured  while  still  plastic  to  the  pos- 
terior aspect  of  the  limb  by  a  roller  bandage.  The  pieces  of  cloth 
should  be  long  enough  to  reach  from  the  ankle  to  the  gluteal  crease, 
and  wide  enough  to  cover  two-thirds  of  the  circumference  of  the  limb ; 
at  the  joint  the  splint  should  not  extend  above  the  most  projecting 
point  of  the  condyles.  Two  thicknesses  of  the  cloth  suffice  for  the 
greater  portion  of  the  splint,  but  these  should  be  reinforced  in  the 
middle  under  the  knee  by  two  extra  layers.  The  adjustment  of  this 
permanent  splint  should  be  deferred  until  the  primary  joint-swelling 
has  subsided.  The  posterior  immobilizing  splint  should  be  retained 
for  six  to  eight  weeks,  but  after  the  first  week  daily  massage  of  the 
quadriceps  femoris  muscle  should  be  made,  access  to  the  anterior  por- 
tion of  the  thigh  requiring  merely  the  temporary  removal  of  the  outer 
bandage.  After  the  third  week  the  whole  apparatus  should  be  daily 
removed,  and  massage  of  the  joint,  with  gentle  passive  movements, 
added.  By  this  method  of  treatment  a  close,  strong,  fibrous  bond 
may  be  secured  with  the  least  amount  of  joint-disability. 

Failure  to  secure  bony  union  is  due  to  the  presence  of  fibrous 
tissue  between  the  fragments,  and  no  prolongation  of  the  period  of 
immobilization,  nor  special  method  of  approximation  will  secure  other 
than  fibrous  union,  unless  this  is  removed.  To  accomplish  this  would 
require  free  exposure  of  the  fracture-surfaces  by  incision  through  the 
overlying  soft  parts,  but  the  risks  of  subsequent  suppuration  within 
the  knee-joint  are  too  great  to  render  such  incision  advisable,  except 
by  a  surgeon  skilled  in  aseptic  operative  technic.  When,  however, 
the  necessary  aseptic  conditions  can  be  secured,  the  fracture  may 
be  exposed  by  a  free*  longitudinal  incision,  the  shreds  of  fibrous  tissue 
and  the  blood-clots  which  cling  to  the  broken  edges  removed,  the 
blood  within  the  joint-cavity  gently  sponged  or  irrigated  out,  and  the 
fragments  secured  in  close  apposition  by  sutures  passed  through  the 
overlying  periosteum,  and  through  the  aponeurosis  on  either  side. 
Chromicized  catgut  is  preferable  for  these  sutures.  The  insertion 
of  silver  wire  through  the  bony  substance  of  the  fragments  to  hold 
them  together  is  unnecessary  and  objectionable,  on  account  of  the 
amount  of  handling  and  bruising  of  the  parts  which  it  entails.  The 
superficial  incision  should  then  be  closed  by  two  tiers  of  sutures, 
one,  of  catgut,  to  the  deep  fascia,  and  one,  subcuticular,  of  silk  or  fine 
silver  thread.  The  posterior  plaster  splint  should  then  be  applied. 
After  four  weeks  this  splint  should  be  left  off,  passive  movements  insti- 
tuted, and  attempts  at  walking  begun.  By  the  end  of  the  sixth  week 
all  restraint  of  the  active  use  of  the  limb  may  be  abandoned,  and  free 
flexion  encouraged.  Cases  thus  treated  show  uniformly  rapid,  firm, 
bony  union,  with  a  minimum  amount  of  peri-articular  stiffness  and 
muscular  atrophy.     The   risks  of  infective  accident  are,  however,  too 


59° 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


great  to  render  this  method  of  treatment  advisable  for  adoption  by  the 
general  practitioner  in  recent  simple  fracture.  In  cases  of  compound 
fracture,  however,  it  should  be  done  as  a  matter  of  routine,  with  special 
precautions  as  to  the  thorough  cleansing  and  drainage  of  the  joint. 
In  old  cases  of  fracture,  with  noticeable  disability  from  non-union, 
exposure  by  incision,  removal  of  intervening  soft  tissue,  refreshing  of 
the  bone-edges,  approximation  and  suture  together  of  the  fragments, 
should  be  done,  if  safeguards  of  asepsis  can  be  assured.  Owing  to 
the  tension  required  in  most  of  such  old  cases  to  bring  the  fragments 
into  apposition,  wiring  of  the  fragments  together  is  usually  called  for 
in  this  class  of  cases. 

Numerous  methods  have  been  suggested  for  tying  the  fragments 
together,  in  recent  cases,  by  thread  passed  under  or  around  them  sub- 
cutaneously,  without  a  free  incision  into  the  in- 
jured area.  All  these  methods,  however,  fail  to 
meet  the  prime  indications  for  removing  the  fibrous 
material  that  may  be  between  the  fragments  and 
of  clearing  the  joint  of  blood-clots,  while  they 
entail  risks  of  infection  nearly  as  great  as  those 
which  attend  open  incision.  The  use  of  steel 
hooks  whose  points,  penetrating  the  skin  until 
they  become  engaged  in  the  anterior  surface  of 
the  fragments,  can  be  approximated,  and  thus 
draw  and  hold  together  the  fragments,  has  only 
historical  interest. 

The  I/eg. — Fractures  of  the  bones  of  the  leg 
are  second  in  the  order  of  frequency  only  to  those 
of  the  bones  of  the  forearm.  In  by  far  the  largest 
proportion  of  cases,  both  the  tibia  and  the  fibula 
are  broken.  The  tibia  and  the  fibula  are  alone 
broken  in  about  equal  degrees  of  frequency.  The 
lower  third  of  these  bones  is  the  most  frequent 
seat  of  fracture,  but  fractures  involving  the  mid- 
dle or  upper  thirds  are  not  infrequent.  All  the 
varieties  of  fracture  and  all  the  causes  of  fracture 
met  with  in  fractures  of  other  long  bones  find 
their  counterpart  in  the  bones  of  the  leg.  In  this 
region  compound  fracture  is  met  with  more  fre- 
quently than  in  any  "other  part  of  the  body,  owing 
to  the  subcutaneous  position  of  the  tibia  and  the 
frequency  with  which  a  direct  blow  or  crushing 
violence  is  sustained  by  the  legs. 

Fracture  involving  the  upper  third  of  the 
bones  of  the  leg  presents  special  conditions  the 
nearer  it  approaches  to  the  knee-joint. 

Impaction    of    the    lower    fragment   into   the 

upper,  with  comminution  of  the  upper  fragment, 

the  lines  of  fracture  opening  into  the  knee-joint, 

may  result  from  falls  upon  the  feet  from  a  height.     Free  hemorrhage 

into  the  cavity  of  the  joint  and  the  involvement  of  the  peri-articular 

structures  in  the  inflammatory  conditions  provoked  by  the  fracture  are 


•     uj&M 

■  ■             M 

I    1           I 

■               I 

■ 

' 

1 

^H           '  V 

FlG.  289. — Comminuted 
fracture  of  the  bones  of  the 
leg.  Machinery  accident ; 
bone-injuries  attended  by 
extensive  laceration  of  soft 
tissues,  necessitating  am- 
putation above  the  knee. 


SPECIAL   FRACTURES. 


591 


unavoidable.  Prolonged  joint-stiffness  and  swelling  are  the  result,  and 
permanent  impairment  of  function  is  possible.  Owing  to  the  proximity 
of  large  blood-vessels  and  important  nerve-trunks,  additional  complica- 
tions due  to  their  laceration  or  compression  occasionally  arise.  Iso- 
lated fracture  of  the  upper  end  of  the  fibula,  which  may  occur  from 
direct  violence  or  from  the  pull  of  the  biceps  muscle  under  certain  con- 
ditions, is  especially  liable  to  have  associated  with  it  rupture  or  contu- 
sion of  the  peroneal  nerve,  and  consequent  paralysis  of  the  structures 
supplied  by  it.  Instances  of  separation  of  the  upper  epiphysis  of  the 
tibia  are  recorded,  in  some  of  which  there  has  resulted  premature  ossi- 


FlG.  290. —  Fracture  of  the  shaft  of  the 
tibia  and  of  the  fibula,  with  external  rotary 
displacement  (Hoffa). 


Fig.  291. — Comminuted  fracture  of  the 
tibia  ;  leg  run  over  by  the  wheel  of  a  street- 
car. 


fkation  of  the  interepiphyseal  cartilage  and  arrest  of  so  much  of  the 
growth  of  the  bone  in  length  as  depends  upon  that  structure. 

The  displacement  attending  fractures  of  the  leg  near  the  knee  is 
usually  merely  that  resulting  directly  from  the  fracturing  force,  and, 
when  once  overcome  by  manipulation,  does  not  tend  to  recur ;  but  in 
some  instances  the  contraction  of  the  hamstring  muscles  is  sufficient 
to  cause  marked  displacement  of  the  fractured  end  of  the  upper  frag- 
ment by  flexing  it  into  the  popliteal  space,  requiring  fixation  of  the 
whole  leg  in  flexion  until  consolidation  has  become  well  advanced,  or 
section  of  the  hamstring-tendons,  to  overcome  the  tendency  to  dis- 
placement. The  head  of  the  fibula,  in  isolated  fracture  of  that  bone, 
may  likewise  be  drawn  upward  by  the  biceps  muscle  away  from  the 
main  portion  of  the  bone  for  an  inch  or  more. 

Fractures  involving  the  shafts  of  the  leg-bones  commonly  exhibit  a 
tendency  to  anterior  angular  displacement  from  the  contraction  of  the 


592 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


muscles  of  the  calf,  which  draw  the  lower  fragment  upward  and  behind 
the  upper,  or  in  front  of  it,  according  to  the  direction  of  the  obliquity 
of  the  fracture-line.  Rotary  displacement  (Fig.  290)  is  likely  to  occur 
from  the  falling  to  one  side  of  the  unsupported  foot. 

The  lower  aids  of  the  bones  are  the  frequent  subjects  of  crushing 
injuries  that  cause  multiple,  often  compound,  fractures  that  involve  the 
ankle-joint ;  but  the  most  common  injury  is  simple  fracture  of  the  fibula 
near  its  lower  end,  with  avulsion  of  the  tip  of  the  internal  malleolus, 
and  either  laceration  of  the  lower  tibiofibular  ligament  or  tearing  away 


Fig.  292.— Fracture  through  lower  third  of  the  shaft  of  the  tibia;  posterior  upward  displace- 
ment of  the  lower  fragment  (Frazier)  (skiagraph  by  Goodspeed). 

of  that  portion  of  the  tibia  into  which  it  is  inserted,  due  to  cross- 
breaking  strain  resulting  from  forcible  eversion  of  the  foot.  The  typi- 
cal condition  is  shown  in  Fig.  293. 

In  more  extreme  cases,  in  which  to  the  everting  force  is  added  a 
vertical  pressure,  as  in  some  falls  upon  the  feet,  the  astragalus  is  driven 
upward,  displacing  upward  and  outward  the  fibular  fragment  and  its 
attached  sliver  of  tibia. 

Forcible  inversion  of  the  foot  may  also  tear  off  the  external  mal- 
leolus, and  in  extreme  cases  the  tip  of  the  internal  malleolus  also. 
Such  injury  is,  however,  of  great  rarity. 

Fracture  of  the  shaft  of  the  tibia  or  of  the  fibula  alone  may  result 


SPECIAL    FRACTURES. 


593 


from  direct  violence.  The  support  given  by  the  unbroken  parallel 
bone  prevents  much  displacement,  and,  by  aiding  immobilization,  con- 
tributes to  rapid  repair  of  the  injury. 

The  prognosis  in  fractures  of  the  bones  of  the  leg  must  often  be 
unfavorably  affected  by  the  associated  injuries.     Simple  fractures  held 
in   proper  apposition  usually  become   firmly  enough   consolidated  to 
bear  the  weight  of  the  body  in  walking  in 
from  six  to  eight  weeks.     A  tendency  to 
edema  and  venous  congestion  persists  for 
months  in  some  cases,  especially  in  per- 
sons past  middle  age.     Aching  after  much 
use  is  often  complained  of  for  a  long  time. 
Delayed   union   in   cases   of  comminuted 
and  of  compound  fracture  is  of  frequent 
occurrence.   Non-union  occurs  with  a  fre- 
quency exceeded  only  by  the  patella  and 
the  humerus. 

Treatment. — Fractures  of  the  leg  are 
best  treated  by  some  form  of  plastic  splint, 
or  by  the  posterior  wire  splint  (Fig.  294), 
after  correction  of  any  displacement  by 
traction  and  manipulation.  Persistent  re- 
currence of  displacement  due  to  obliquity 
of  the  fracture  and  muscular  spasm  calls 
for  relaxation  of  the  affected  muscles  by 
position  or  by  tenotomy.  Division  of  the 
tendo  Achillis  may  be  unhesitatingly  re- 
sorted to  for  overcoming  deformity  caused 
by  contraction  of  the  calf-muscles.  If  the 
fracture  is  unattended  by  much  laceration 
or  contusion  of  the  soft  parts,  a  plaster-of- 
Paris  roller  bandage  may  be  at  once  ap- 
plied over  a  single  layer  of  cotton  wadding 
by  which  the  part  has  been  first  wrapped 
(see  section  on  General  Considerations,  page  514).  Careful  watch  of 
the  toes,  always  left  exposed  for  observation,  should  be  maintained 
at  first,  until  it  is  evident  that  there  is  no  impediment  to  the  free  cir- 
culation of  blood  in  the  parts  distal  to  the  fracture.  Should  numb- 
ness, or  lividity,  or  pallor  of  the  toes  develop,  the  splint  should  at 
once  be  cut  open  throughout  its  length,  and  sprung  open  sufficiently 
to  relieve  the  constriction.  The  plaster  roller  should  never  be  pri- 
marily applied  to  a  case  which  cannot  be  thus  watched.  If  the 
plaster  bandage  is  well  borne,  the  patient  may  be  allowed  to  get  up 
from  bed  and  move  about  upon  crutches  with  considerable  freedom 
as  soon  as  the  primary  pain  and  tenderness  occasioned  by  the  trauma- 
tism have  subsided.  Whenever,  by  reason  of  the  absorption  of  effu- 
sions or  the  atrophy  of  tissue,  the  plaster  case  gets  loose,  it  should  be 
removed  and  another  applied.  In  any  case  it  should  be  taken  off  at 
the  end  of  the  first  week  for  inspection  and  readjustment,  if  necessary, 
of  the  fracture,  and,  everything  being  favorable,  a  new  bandage  applied. 
If  the  injury  to  the  soft  parts  is  such  as  to   make  the  safety  of  the 

38 


Fig.  293. — Fracture  of  the  fibula, 
with  fracture  of  the  tip  of  the  inter- 
nal malleolus  and  of  the  fibular 
articular  surface  of  the  tibia  from 
violent  eversion  of  the  foot  (Pott's 
fracture)  (Hoffa). 


594 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


immediate  application  of  the  plaster  roller  questionable,  a  posterior 
plaster  gutter,  as  advised  in  the  case  of  the  patella,  should  be  resorted 
to.  The  splint  should  extend  from  above  the  knee  to  the  base  of  the 
toes,  and  should  leave  the  anterior  third  of  the  leg  exposed  (sec  Fig. 
295)  It  is  best  held  in  place  by  a  many-tailed  bandage  which  per- 
mits the  frequent  inspection  of  the  site  of  fracture  without  any  disturb- 


FlG.  294. —  Fracture  of  leg  immobilized  in  a  posterior  wire  splint. 

ance  of  the  fragments.  When  the  swelling  has  subsided,  usually 
during  the  second  week,  the  plaster  roller  bandage  may  be  substituted 
for  the  gutter. 

Special  care  is  to  be  exercised  in  the  application  of  these  dressings 
that  the  foot  be  kept  up  to  a  right  angle  with  the  long  axis  of  the  leg, 
and  that  no   lateral  deviation   occur,  the  head  of  the  first   metatarsal 


FlG.  295. — Posterior  gypsum  gutter-splint. 

bone  being  in  the  same  line  with  the  inner  edge  of  the  patella  and  the 
anterior  superior  spine  of  the  ilium. 

For  the  temporary  fixation  of  the  fragments,  until  place  and  mate- 
rials for  the  plastic  dressings  can  be  procured,  well-padded  strips  of 
board  secured  to  the  limb  by  circular  turns  of  bandage  will  serve  a 
good  purpose.  Three  strips,  one  posterior  and  one  for  each  side, 
should  be  used  ;  they  should  extend  from  the  middle  of  the  thigh 
above  to  beyond  the  sole  of  the  foot  below ;  they  should  be  so  padded 


SPECIAL   FRACTURES.  595 

as  to  fit  the  inequalities  of  the  limb  when  snugly  drawn  up  to  it  by  the 
bandage ;  they  should  be  wide  enough,  so  that  the  encircling  bandage 
when  applied  should  not  touch  the  leg.  For  the  special  care  required 
in  the  treatment  of  compound  fractures,  see  page  516. 

Ambulatory  Dressings. — In  cases  suitable  for  the  application  of  the 
plaster  bandage,  it  is  possible  so  to  adjust  the  dressing  that  the  portion 


Fig.  296. —  Ambulatory  dressing  for  fracture  of  the  bones  of  the  leg. 

of  the  limb  distal  to  the  fracture  may  be  suspended  in  the  rigid  dress- 
ing which  has  been  made  to  extend  beyond  the  sole  of  the  foot  below 
by  interposing  an  inch  thickness  of  cotton  between  the  sole  of  the  foot 
and  that  portion  of  the  bandage  which  comes  in  contact  with  the 
ground,  the  upper  part  of  the  dressing  grasping  the  prominences  about 
the  knee  and  the  conical  surfaces  of  the  thigh,  so  as  to  transmit  the 
weight  of  the  body  from  them  through  the  splint  to  the  ground,  with- 
out disturbing  the  seat  of  fracture.  The  swinging,  dependent  position 
of  the  limb  and  the  muscular  movements  required  in  the  efforts  to  use 
such  a  limb  actively  in  locomotion  produce  nutritive  conditions  more 


596  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

favorable  to  repair  than  those  which  attend  the  anemia  caused  by  the 
elevated  position,  the  bandaging,  and  the  disuse  which  are  a  part  of 
the  methods  of  treatment  usually  followed.  Special  watchfulness 
against  possible  pressure-necrosis  is  required  in  the  use  of  such  a 
dressing,  and  it  should  not  be  ventured  upon  in  cases  in  which  the 
prominences  about  the  knee  are  excoriated  or  edematous. 

For  its  proper  application  practical  familiarity  with  the  ordinary 
application  of  the  plaster  bandage  is  requisite,  and  it  is  not  to  be  recom- 
mended for  use  by  the  general  practitioner.  In  the  hands,  however, 
of  surgeons  who  have  the  necessary  technical  skill  and  experience, 
this  ambulatory  dressing  may  be  applied  in  most  cases  of  simple  fract- 
ure of  the  leg,  with  the  result  of  avoiding  in  many  cases  the  disadvan- 
tage of  prolonged  detention  from  the  activities  of  life,  of  expediting  the 
full  consolidation  of  the  fracture,  and  of  securing  an  earlier  restoration 
of  the  full  functions  of  the  limb. 

The  Bones  of  the  Foot. — Fractures  of  the  astragalus  or  of  the 
os  calcis  are  more  commonly  the  result  of  a  fall  from  a  height,  the 
weight  of  the  body  being  received  squarely  upon  the  sole  of  the  foot. 
Some  comminution  is  the  usual  accompaniment,  and  dislocation,  often 
compound,  is  a  frequent  complication.  A  portion  of  the  os  calcis  may 
be  torn  off  by  violent  contraction  of  the  calf-muscles.  Crushing  injuries 
from  direct  violence  may  present  every  degree  of  comminution  of  these 
bones  and  laceration  of  the  overlying  soft  tissues. 

In  the  case  of  compound  injuries  not  requiring  amputation,  excision 
of  loose  fragments,  and  even  of  the  entire  astragalus,  may  be  indicated. 
In  the  less  severe  injuries,  after  the  fragments  have  been  moulded  into 
place,  retention  is  best  secured  by  a  plaster-of-Paris  bandage,  especial 
care  being  taken  that  the  foot,  when  fixed,  is  flexed  at  a  right  angle  to 
the  leg.  When  the  contraction  of  the  calf-muscles  tends  to  draw  away 
a  fragment  of  the  os  calcis,  section  of  the  tendo  Achillis  should  be  made. 

The  metatarsal  bones  and  the  phalanges  of  the  toes  are  frequently 
the  subjects  of  crushing  injuries,  calling  for  amputation  or  for  excision 
in  their  treatment. 


CHAPTER    XVII. 
INJURIES   TO   THE  JOINTS;    DISLOCATIONS. 

INJURIES   TO  THE  JOINTS. 

The  joints,  although  strong  and  well  arranged  to  resist  violence, 
none  the  less,  as  the  parts  of  the  body  in  which  mobility  is  greatest, 
form  weak  points  in  the  economy,  and  as  such  furnish  the  subject  of 
an  important  chapter  in  the  surgery  both  of  injury  and  disease. 

Importance  of  Injuries  to  the  Joints.— This  is  to  be  regarded 
first  as  to  the  degree  of  immediate  local  injury.  This  may  be  so  severe 
or  complicated  by  so  extensive  coexistent  damage  to  the  soft  parts  as 
to  endanger  the  safety  of  the  limb;  or,  on  the  other  hand,  the  structures 
proper  to  the  joint  itself  may  alone  materially  suffer.  Such  injuries 
may  be  completely  recovered  from,  or  they  may  leave  behind  them  a 
tendency  to  recurrent  inflammation,  a  certain  degree  of  physical  weak- 
ness, or  a  varying  degree  of  interference  with  the  normal  range  of 
motion  of  the  joint. 

The  special  importance  of  the  slighter  injuries  to  the  joints  lies, 
however,  in  their  relation  to  the  various  constitutional  diatheses,  wherein 
even  a  very  slight  trauma  may  lead  to  the  most  serious  results.  This 
connection  is  perhaps  most  strikingly  exemplified  in  tuberculous  dis- 
ease. Here  the  number  of  cases  in  which  the  affection  dates  from  an 
injury  often  marked  by  insignificant  immediate  results  is  astonishingly 
great.  Though  less  frequent,  yet  not  less  important  is  a  similar  his- 
tory in  the  case  of  joint-suppuration  secondary  to  acute  infective  bone- 
inflammation  in  the  young.  Again,  the  course  of  joint-injuries  may  be 
seriously  influenced  by  the  gouty  or  rheumatic  diathesis,  and  still  more 
importantly  by  the  hemophilic.  A  form  of  arthritis  destructive  in 
character  is,  moreover,  sometimes  induced  in  old  persons  or  even  in 
adult  life,  best  known  as  chronic  traumatic  arthritis. 

Contusions. — These  injuries  are  common,  and  vary  considerably 
in  severity  and  importance.  The  superficial  position  of  some  articula- 
tions renders  them  liable  to  considerable  contusion  as  the  result  of 
comparatively  slight  violence,  while  others  are  protected  by  their  deep 
situation.  As  in  so  many  other  instances,  the  knee-joint  takes  the  first 
place  in  this  respect,  in  consequence  of  its  exposed  and  superficial 
position,  its  functional  importance,  and  its  size  and  strength. 

Contusions  are  either  caused  by  blows  with  blunt  bodies,  or  are  the 
result  of  striking  the  joint  against  the  ground  in  a  fall.  In  the  slighter 
forms  these  injuries  are  followed  by  superficial  ecchymosis  and  a  vary- 
ing degree  of  joint-effusion,  the  fluid  consisting  of  an  admixture  of 
blood  and  synovia  in  different  proportions.  Such  effusions  are  usually 
attended  by  the  appearance  of  local  swelling,  heat,  and  more  or  less 
pain  from  tension — the  signs,  in  short,  of  simple  synovitis,  the  direct 


597 


598  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

result  of  trauma — and  perhaps  by  the  presence  of  blood  in  the  joint- 
cavity.  In  the  absence  of  any  diathetic  complication,  the  ordinary 
course  is  to   resolution. 

From  the  nature  of  the  violence  producing  them,  however,  con- 
tusions of  the  joints  are  often  complicated  by  very  severe  injury  to  the 
surrounding  soft  parts — the  skin,  subcutaneous  tissue,  the  bursae,  the 
muscles  and  tendons,  the  vessels,  the  nerves,  or  the  bones  being  more 
or  less  implicated.  In  many  of  these  instances  the  joint-lesion  takes  a 
secondary  place.  Effusion  into  the  bursae,  of  the  same  nature  as  that 
within  the  articular  cavity,  often  complicates  a  joint-contusion,  and  may 
lead  to  some  difficulty  in  diagnosis,  the  bursa,  as  the  more  superficial 
structure,  sometimes  giving  rise  to  the  more  prominent  initial  signs  and 
symptoms.  Small  fragments  of  the  bones  or  cartilages  may  be  broken 
off,  too  insignificant  to  lead  to  the  case  being  classed  as  one  of  fracture, 
but  yet,  in  view  of  possible  after-results,  needing  an  equal  amount  of 
care  in  treatment. 

The  ordinary  course  of  these  injuries,  when  occurring  in  healthy 
persons  and  moderate  in  degree,  is  to  resolution  and  complete  recovery. 
Certain  after-consequences,  however,  are  common  ;  the  least  important 
of  these  is  the  persistence  of  local  pain,  with  some  consequent  limita- 
tion of  function.  Again,  simple  effusion  may  persist  for  some  con- 
siderable time.  When  portions  of  the  bone  or  cartilage  are  broken 
off,  these  may  so  unite  as  to  interfere  with  the  proper  movements  of 
the  joint,  or  they  may  remain  as  loose  bodies,  giving  rise  to  the  ordinary 
train  of  symptoms  observed  when  these  are  present.  With  regard  to 
the  latter  point,  however,  it  should  be  noted  that  separation  of  loose 
fragments  is  rare  in  the  absence  of  previous  pathological  change,  a 
change  which  is  usually  of  the  nature  of  chronic  rheumatoid  arthritis,  in 
which  the  articular  margins  are  unduly  prominent. 

Treatment  of  Contusions. — Slight  contusions  are  best  treated  by 
rest  and  the  application  of  cooling  lotions  or  by  hot  bathing ;  more 
severe  ones,  by  a  splint  and  an  ice-bag  or  Leiter's  tubes.  In  cases, 
however,  where  ecchymosis  is  a  prominent  feature,  great  caution  should 
be  exercised  in  the  application  of  ice,  since  the  lowering  of  the  tem- 
perature may  so  interfere  with  the  vitality  of  the  skin  -as  to  lead  to 
gangrene.  If  effusion  is  the  prominent  symptom,  no  better  treatment 
can  be  adopted  than  the  immediate  application  of  a  plaster-of-Paris 
splint;  but  this,  as  a  rule,  should  not  be  kept  on  for  more  than  a  few 
days,  as  too  prolonged  fixation  may  lead  to  troublesome  stiffness  of 
the  joint.  When  the  splint  is  removed,  hot  bathing  and  gentle  exercise 
will  help  to  ensure  the  early  resumption  of  the  normal  mobility.  If 
the  treatment  needs  to  be  at  all  prolonged,  massage  is  most  useful. 
This  maybe  commenced  while  the  joint  is  still  tender,  but  in  this  stage 
it  should  be  directed  to  the  muscles  acting  on  the  articulation,  and  not 
to  the  tender  joint  itself. 

Sprains  of  Joints. — This  term  is  used  to  describe  injuries  of 
joints  resulting  from  forcible  movements  in  which  the  normal  range 
is  exceeded.  Sprains  may  be  produced  by  false  movements,  too  great 
voluntary  muscular  efforts,  or  by  blows  or  falls.  Such  injuries  may 
result  in  mere  nipping  of  the  synovial  fringes,  in  more  or  less  exten- 
sive rupture  of  the  ligaments,  or  in   separation   of  small  fragments  of 


INJURIES    TO    THE  JOINTS.  599 

bone  together  with  the  latter  structures.  Sprains  are  also  necessarily 
attended  by  much  stretching  of  the  tendons  and  tendon-sheaths  sur- 
rounding the  articulation. 

The  immediate  result  is  the  establishment  of  an  abnormal  degree 
of  mobility,  and  hence  weakness  and  want  of  proper  stability.  This 
condition  is  accompanied  by  pain,  and  is  followed  by  effusion  into  the 
joint-cavity,  and  often  also  into  the  tendon-sheaths  surrounding  the 
joint.  At  a  later  date  ecchymosis  occurs,  when  the  deeply  effused 
blood   has   had  time  to   make  its  way  to  the   surface. 

Results  of  Sprains. — Much  that  has  been  said  as  to  the  results  of 
joint-injuries  in  general,  and  as  to  the  results  of  contusions,  applies 
equally  well  in  the  case  of  sprains.  One  result,  however,  must  be 
specially  mentioned — namely,  the  persistent  weakness  due  to  abnormal 
mobility.  This  may  depend  on  the  stretching  of  the  ligaments  due  to 
long-standing  effusion,  to  insufficient  repair  of  an  injured  ligament,  or 
to  the  stretching  of  the  new  cicatrix.  Careful  fixation  of  the  joint  at 
the  time  of  injury  is  therefore  the  special  indication  in  the  treatment  of 
these  injuries. 

Treatment  of  Sprains. — Here  again  much  that  has  been  said  as 
to  the  treatment  of  contusions  applies,  but  two  points  need  special 
mention — first,  that  effusion  is  often  a  prominent  sign  ;  and  secondly, 
that  every  effort  must  be  made  to  prevent  the  persistence  of  abnormal 
mobility.  Both  conditions  are  best  treated  by  immobilization  in  a 
plaster-of- Paris  splint.  For  effusion  alone,  this  should  not  be  long 
retained;  but  when  rupture  of  ligaments  has  been  diagnosed  by  the 
presence  of  abnormal  mobility  in  any  direction,  it  may  need  to  be  con- 
tinued three  or  more  weeks.  The  splint  is  best  made  of  Bavarian  flannel, 
so  as  to  allow  of  its  being  tightened  up  or  removed  as  swelling 
decreases  or  massage  is  thought  desirable.  In  the  case  of  the  great 
weight-bearing  joints,  such  as  the  knee,  a  leather  support  with  lateral 
hinges,  so  as  to  allow  of  flexion  and  extension  of  the  joint,  and  yet 
fully  control  any  lateral  movement,  is  often  useful  when  the  plaster  is 
removed.     It  may  be  worn  several  months  with  advantage. 

Massage  should  be  begun  early,  in  order  to  avoid,  as  far  as  possible, 
weakness  of  the  muscles,  and  to  ensure  security  to  the  position  of  the 
joint  by  the  retention  of  a  proper  tone  in  them.  As  in  contusions,  the 
rubbing  should  be  applied  to  the  muscles  while  the  joint  itself  is  too 
tender  to  bear  direct  manipulation  ;  and,  in  fact,  it  is  to  the  muscles 
rather  than  to  the  joint  itself  that  this  treatment  is  the  more  useful. 
In  some  cases,  particularly  the  ankle  and  wrist,  effusion  into  the 
tendon-sheaths  around  the  articulation  may  be  a  more  prominent 
feature  than  the  joint-effusion  itself.  The  same  treatment  in  the  main 
should  be  adopted,  bearing  in  mind  the  necessity  of  earlier  movement 
in  the  case  of  the  tendon-sheaths,  and  the  special  efficacy  of  frictional 
treatment.  Beyond  massage,  properly  limited  and  graduated  exercises, 
so  arranged  that  the  supporting  tendons  are  braced,  while  the  damaged 
part  of  the  joint-capsule  is  not  stretched,  are  of  great  value. 

A  word  of  warning  should  be  added  here  as  to  the  treatment  of 
these  injuries  when  they  occur  in  gouty  subjects.  Very  considerable 
inflammatory  signs  are  often  developed,  so  as  to  arouse  the  suspicion 
of  suppuration.     Such  cases  should  be  treated  with  the  utmost  caution, 


600  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

and  on  no  account  should  an  incision  be  made  without  absolute  con- 
viction of  its  necessity,  since  such  a  procedure  often  gives  rise  to  wide- 
spread cellulitis  and  prolonged  suppuration. 

Wounds  of  Joints. — These  may  be  punctured,  incised,  contused, 
or  lacerated ;  and  their  relative  gravity  depends  on  the  possession  of 
one  or  other  of  these  characteristics,  and  on  the  nature  of  the  instru- 
ment by  which  they  have  been  produced. 

Signs  of  Wound  of  a  Joint. — When  a  wound  is  of  the  punctured 
variety,  small,  very  oblique,  or  complicated  by  extensive  laceration  of 
the  skin,  situated  at  some  little  distance  from  the  joint  itself,  some  dif- 
ficulty may  arise  in  determining  whether  the  articulation  has  been 
opened  or  not.  The  pathognomonic  sign  is  the  escape  of  synovial 
fluid.  This  is  usually  sufficient  proof,  but  it  is  by  no  means  always 
present ;  and  beyond  this  we  have  to  bear  in  mind  the  possible  escape 
of  small  quantities  of  similar  fluid  from  bursas  or  tendon-sheaths  in  the 
immediate  vicinity.  Giving  full  importance  to  this  sign,  therefore, 
when  it  exists,  we'  have  often  to  decide  in  its  absence,  and  then  depend 
mainly  on  the  history  of  the  case,  careful  examination  of  the  wound, 
the  position  of  the  opening,  and  on  the  occurrence  of  rapid  effusion 
of  either  synovia  or  blood  into  the  joint-cavity. 

Suppuration  of  a  Joint. — The  occurrence  of  synovitis  in  a  varying 
degree  is  to  be  expected  in  most  cases,  and  the  injury  begins  to  acquire 
special  importance  only  when  further  changes  lead  us  to  suspect  the 
advent  of  suppuration.  The  mode  of  onset  of  this  may  vary  consider- 
ably. In  the  most  acute  cases  the  temperature  at  once  rises  to  1020  F. 
or  more,  often  with  the  concurrence  of  a  rigor,  and  always  with  a 
decided  increase  in  the  amount  of  pain  experienced.  Meanwhile  the 
pulse  steadily  gains  in  frequency  and  acquires  a  bounding  character. 
Swelling  of  the  joint  becomes  more  marked,  the  tension  often  becoming 
extreme  ;  redness  and  edema  of  the  surface  appear.  The  pain  is  acute, 
constant,  and  accompanied  by  exacerbations  due  to  the  relaxation  of  the 
spasmodically  contracted  muscles,  which  latter  gives  rise  to  sudden  starts 
that  destroy  any  chance  of  the  patient's  obtaining  proper  sleep.  Sleep- 
lessness, again,  is  an  important  indication  of  constitutional  absorption. 

If  unrelieved,  the  process  extends,  infection  travelling  by  the  original 
route  of  the  wound  into  the  areolar  planes  in  the  neighborhood  of  the 
joint,  and  into  any  bursal  extensions  which  may  exist.  The  extension 
may  be  so  widespread  as  to  involve  the  whole  limb,  if  the  patient's 
strength  holds  out  long  enough  ;  but,  on  the  other  hand,  it  may  be 
checked  by  timely  incision  of  the  joint  and  the  affected  area  of  the 
limb.  Together  with  the  extra-articular  changes,  continuous  destruc- 
tion proceeds  within  the  joint  itself,  the  synovial  membrane  becomes 
transformed  into  a  mass  of  granulation-tissue,  or  sloughs ;  the  carti- 
lages become  eroded  and  separated,  and  the  bones  denuded  of  their 
periosteum.  These  local  processes  are  accompanied  by  a  continuance 
of  the  general  symptoms  already  detailed  ;  the  temperature  may  rise  to 
1040  or  1050  F.,  and  profuse  perspiration  occurs  at  night.  The  pulse 
gains  in  rapidity  and  loses  in  strength,  the  appetite  is  lost,  the  tongue 
becomes  dry,  furred,  and  brown,  and  pain  and  the  drain  due  to  the 
suppuration  rapidly  produce  exhaustion.  Again,  a  fatal  termination 
may  be  hastened  by  the  supervention   of  septicemia  or  pyemia. 


INJURIES    TO    THE  JOINTS.  Co  I 

In  other  cases,  the  process  is  by  no  means  so  acute  in  its  onset  or 
subsequent  progress.  The  first  signs  of  trouble  are  a  slighter  rise  of 
temperature,  acceleration  of  the  pulse,  and  a  less  amount  of  swelling 
and  pain.  If  an  opening  exists  by  which  synovial  fluid  escapes,  this 
will  be  first  noticed  to  contain  flakes  of  lymph,  and  later  become  puru- 
lent ;  or  similar  characters  will  be  noted  in  synovia  drawn  off  with  the 
aspirator.  If  uninterfered  with  by  treatment,  the  further  changes  may 
resemble  those  already  detailed,  the  various  stages  being  only  more 
slowly  developed. 

Results  of  Wounds  of  Joints — The  immediate  results  of  wounds 
of  joints  have  been  considered  in  the  preceding  paragraphs,  it  only 
remains  to  say  a  word  concerning  the  more  remote.  First,  should  a 
large  joint  suppurate,  the  serious  attendant  illness  must  set  a  material 
mark  on  the  constitution  of  the  patient ;  secondly,  even  the  slighter 
forms  of  inflammation  may  be  followed  by  troublesome  stiffness  of  a 
more  or  less  permanent  nature,  and  in  the  severer  forms  this  may 
amount  to  complete  ankylosis,  either  of  the  fibrous  or  the  bony  variety. 
Again,  the  termination  of  the  period  of  acute  suppuration  may  be  only 
the  commencement  of  a  chronic  arthritis  of  indefinite  duration. 

Treatment  of  Wounds  of  Joints. — When  the  wound  is  small,  the 
first  point  for  decision  is  whether  the  joint  should  be  opened  up  and 
thoroughly  disinfected.  In  deciding  this  question,  we  are  mainly  influ- 
enced by  the  nature  of  the  instrument  that  produced  the  injury.  If 
this  was  small  and,  as  far  as  we  can  judge,  clean,  the  best  course  is  to 
seal  the  wound,  place  the  limb  upon  a  splint,  and  await  events.  If  the 
wound  is  larger,  it  is  better  at  once  to  take  steps  to  render  both  the 
wound  and  the  joint  itself  as  aseptic  as  may  be  in  our  power.  The 
next  question  is  that  of  drainage.  If  this  be  decided  upon,  the  tube 
should  be  inserted  at  the  most  dependent  part  of  the  articulation.  In 
many  cases  it  is  preferable  to  close  the  joint,  apply  pressure,  and,  in 
the  event  of  free  effusion,  to  insert  a  director,  and  thus  evacuate  the 
fluid  and  relieve  tension,  this  procedure  being  repeated  as  often  as  may 
prove  necessary.  In  any  case,  if  a  tube  is  inserted,  it  should  be  dis- 
pensed with  as  soon  as  possible. 

The  wound  once  healed,  the  further  treatment  of  the  case  is  that  of 
a  simple  one  of  traumatic  synovitis.  If  we  should  fail  in  our  first 
effort  to  asepticize  the  joint,  and  suppuration  should  follow,  the  articu- 
lation must  be  incised  and  thoroughly  drained.  The  sooner  this  is 
undertaken,  the  better  chance  there  is  of  preventing  widespread  infec- 
tion of  the  surrounding  tissues  and  the  development  of  hopeless 
destructive  changes  in  the  joint.  This  most  important  step  having 
been  taken,  the  next  question  is  the  best  mode  of  dressing  the  wounds. 
Three  forms  of  treatment  are  open  to  us :  I .  To  dress  frequently,  so 
as  to  remove  all  discharge  at  the  earliest  moment  possible ;  2.  To  set 
up  a  constant  irrigation-apparatus  ;  3.  To  place  the  patient  or  the  limb 
in  an  antiseptic  bath.  The  main  objection  to  the  first  plan  is  the 
exhaustion  often  caused  to  the  patient  by  the  process  of  dressing; 
nevertheless,  this  is  sometimes  necessary,  and  if  the  joint  drains  freely 
and  the  discharge  is  not  very  abundant,  it  is  often  the  best  plan.  Con- 
stant irrigation  often  gives  excellent  results ;  but  this  also  is  exhausting 
to   the   patient,  especially  if  a   large  joint  is   affected.     If  chosen,  it 


602  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

should  be  arranged  with  a  tank  of  antiseptic  fluid  kept  at  a  uniform 
temperature  of  ioo°  F.,  the  fluid  being  conveyed  across  the  joint  by 
properly  arranged  tubes.  The  process  may  then  be  continued  for  sev- 
eral days  with  intermissions.  Both  it  and  the  next  method  are  particu- 
larly indicated  where  there  are  abundant  suppuration  and  sloughing. 
The  constant  bath  is  most  useful  in  the  case  of  the  small  joints  of  the 
extremities,  or  in  children,  whose  entire  bodies  may  be  immersed,  the 
temperature  of  the  fluid  being  carefully  regulated.  Excellent  results 
are  to  be  obtained  in  suppurating  knee-joints  in  children  by  this  method, 
the  limb  being  placed  on  a  back  splint  in  the  bath.  The  best  fluids  to 
employ  are  those  of  a  non-poisonous  character,  such  as  boric-acid 
lotion,  or  creolin  i  :  300  or  400,  especially  the  latter.  If  perchlorid 
lotion  is  employed,  it  must  not  be  stronger  than  1  :  5000,  and  great 
care  must  be  taken  to  watch  the  patient  narrowly.  Neither  irrigation 
nor  bath-treatment  should  be  continued  if  the  limb  becomes  sodden. 

During  the  carrying  out  of  these  local  methods,  the  patient  should 
be  kept  up  by  the  free  administration  of  fluid  nourishment,  combined 
with  a  sufficient  supply  of  stimulant ;  quinin  may  be  administered  inter- 
nally. If  the  organism  causing  suppuration  should  be  proved  to  be  a 
streptococcus,  the  question  of  the  employment  of  antistreptococcic 
serum  must  also  be  considered,  especially  if  the  constitutional  symptoms 
are  severe.  Should  our  efforts  to  check  the  mischief  fail  and  the 
patient  shows   signs   of  sinking,  amputation   may  be  necessary. 

DISLOCATION  OF  JOINTS. 

This  term  is  applied  to  the  condition  in  which  one  or  other  of  the 
bones  entering  into  the  formation  of  an  articulation  is  permanently  dis- 
placed. The  dislocation  takes  its  name  from  the  distal  of  the  two 
bones  ;  tlfus,  a  dislocation  of  the  shoulder-joint  is  understood  to  mean 
a  displacement  of  the  humerus. 

Dislocations  are  most  conveniently  classed  according  to  their  causes, 
and  by  this  method  the  following  four  varieties  may  be  distinguished : 
1.  Traumatic;  2.  Congenital;   3.  Spontaneous;  4.   Pathological. 

Beyond  this,  dislocations  are  sometimes  spoken  of  as  complete  and 
incomplete. 

The  comparative  frequency  of  dislocation  of  the  individual  joints 
differs  greatly,  the  variation  depending  mostly  on  the  anatomical  dispo- 
sition of  the  joint,  the  age,  sex,  and  occupation  of  the  patient.  The 
statistics  given  on  page  604,  compiled  from  the  records  of  St.  Thomas's 
Hospital,  London,  offer  a  very  fair  view  of  the  influence  of  these  factors, 
since  great  care  has  been  taken  to  include  all  dislocations  of  the  upper 
extremity  treated  at  the  hospital. 

Causation. — Displacement  may  be  the  result :  I.  Of  external  vio- 
lation ;  II.  Of  muscular  action;  III.  Of  pathological  changes  in  the 
ligaments  ;  or  IV.  of  a  congenital  deficiency  in  the  development  of  the 
joint. 

External  Violence. — This  may  be  direct  in  its  nature,  when  the 
articular  end  of  the  bone  is  driven  against  a  limited  portion  of  the 
capsule,  which  gives  way  at  that  spot  and  allows  the  escape  of  the 
bone  in  a  corresponding  direction.     The  further  course  may  be  influ- 


DISLOCATION  OF  JOINTS.  603 

enced  by  the  continued  exertion  of  the  violence,  the  force  of  gravity, 
the  normal  elasticity  of  the  muscles  and  other  structures  surrounding 
the  articulation,  and  the  amount  of  injury  to  surrounding  parts  ;  but 
in  all  cases  its  final  direction  and  extent  are  determined  by  the  portion 
of  the  capsule  which  remains  intact.  Direct  violence  is  responsible  for 
a  considerable  proportion  of  the  less  common  dislocations,  such  as 
those  of  the  humerus  backward,  or  of  the  tibia  from  the  femur. 

Indirect  violence  is  a  much  more  fruitful  source  of  dislocation,  the 
force  being  applied  at  some  distance  from  the  affected  joint,  and  the 
leverage  exerted  corresponding  either  with  the  length  of  the  bone  or 
often  of  the  whole  limb.  A  very  great  majority  of  the  more  common 
dislocations  of  the  type-forms  are  produced  in  this  manner,  certain 
definite  portions  of  the  capsule  being  especially  liable  to  rupture  in 
the  different  joints,  and  the  permanent  position  of  the  displaced  bone 
depending  on  the  same  factors  that  have  already  been  enumerated  in 
speaking  of  dislocations  from  direct  violence.  Such  dislocations  are 
naturally  less  liable  to  be  accompanied  by  severe  local  injury  to  the 
soft  parts.  Indirect  violence  in  almost  all  cases  carries  a  natural 
physiological  movement  beyond  its  normal  limit ;  and  it  may  be  noted 
that  of  all  movements,  that  of  forced  abduction  is  the  most  generally 
dangerous. 

Muscular  Action. — What  has  been  said  of  dislocation  by  indirect 
violence  holds  almost  equally  well  for  the  explanation  of  dislocation 
by  the  forcible  contraction  of  the  muscles.  The  only  distinction  is 
that  the  range  of  leverage  which  can  be  exerted  is  not  so  great. 
Thus,  many  such  dislocations,  notably  that  of  the  mandible,  really 
depend  on  a  very  slight  exaggeration  of  the  normal  physiological 
movement  of  the  joint.  Such  dislocations  are  not  uncommon  in  con- 
vulsions from  epilepsy  or  other  causes,  or  may  be  the  result  of  forci- 
ble use  of  a  limb,  as  in  striking  out  the  fist,  or  in  lifting  heavier  weights 
than  the  individual's  strength  warrants. 

The  occurrence  of  certain  conditions  generally  favoring  dis- 
locations must  be  here  briefly  considered. 

Anatomical  Peculiarities  and  Exposed  Position  of  the  Joint. — 
These  will  be  dealt  with  under  the  heading  of  the  Special  Joints.  It 
suffices  here  to  point  to  the  frequency  of  dislocations  of  the  shoulder- 
joint  as  the  most  striking  exemplification  of  these  influences. 

Age. — Taken  as  a  whole,  it  is  no  doubt  correct  to  say  that  the  pre- 
disposition to  dislocation  increases  steadily  from  the  first  decennium 
upward,  and  in  the  table  on  page  604  this  point  is  practically  borne 
out. 

The  comparative  infrequency  in  children  is  to  be  explained  by  the  fact  that  the  attach- 
ment of  the  joint-capsule  is  of  a  stronger  nature  than  the  connection  between  the  epiphysis 
and  diaphysis  ;  hence,  experience  has  shown  that  the  traumatic  separation  of  the  latter  in 
part  takes  the  place  of  dislocation.  Again,  the  slighter  body-weight,  greater  elasticity, 
comparative  weakness  of,  the  shafts  of  the  bones,  and  freedom  from  laborious  occupation  in 
childhood  are  all  unfavorable  to  the  occurrence  of  dislocation. 

The  increase  in  strength  and  aptitude  in  the  muscles  concomitant  with  the  years  of  most 
active  existence  lowers  the  danger  in  adult  life,  while  with  the  approach  of  old  age  the 
gradual  atrophy  of  the  bones  and  ligaments  and  the  loss  of  elasticity  of  the  muscles  lower 
both  the  capacity  to  withstand  violence  from  without  and  the  capability  of  avoiding  it.  As 
has  been  pointed  out  by  Kronlein,  the  relative  frequency  in- old  age  is  far  greater  than  the 
actual,  if  the  number  of  dislocations  is  compared  with  that  of  persons  of  fifty  years  of  age 
and  upward,  since  the  latter  is  naturally  small  compared  with  the  number"  under  that  limit. 


604 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


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DISLOCATION   OF  JOINTS.  60$ 

Sex. — As  in  the  case  of  most  traumata,  the  male  sex  is  far  the  more 
liable  to  these  accidents,  on  account  of  the  more  active  nature  of  the 
occupation  pursued.  In  the  St.  Thomas's  table  of  1207  dislocations, 
869,  or  71.99  per  cent.,  occurred  in  men;  338,  or  28  per  cent.,  in 
women. 

Occupation  and  Degree  of  Muscular  Education  and  Development. 
— The  occupation  of  the  individual  necessarily  exercises  a  most  impor- 
tant influence  on  the  liability  to  dislocation. 

Many  callings,  from  their  intrinsic  nature,  expose  the  individual  to  chances  of  external 
violence  quite  outside  the  experiences  of  ordinary  life.  But  against  this  we  have  to  put  the 
fact  that  persons  whose  work  needs  great  muscular  effort  are  usually  well  developed  and 
able  to  bear  safely  strains  which  would  be  of  great  danger  to  the  ordinary  individual. 
Again,  it  is  not  only  a  question  of  mere  strength,  but  also  of  what  may  be  called  education. 
It  has  been  remarked  by  Sir  Astley  Cooper  that,  given  a  contracted  state  of  the  muscles,  a 
dislocation  is  an  impossibility  ;  and  there  exists  no  doubt  that  those  whose  calling  depends 
mostly  on  the  use  of  the  muscles  possess  a  capacity  to  withstand  strain  far  above  that  pos- 
sessed by  those  whose  occupation  is  of  a  lighter  or  more  sedentary  nature. 

Lastly,  the  occurrence  of  dislocation  in  some  individuals  may  be 
facilitated  by  the  existence  of  an  abnormal  laxity  of  the  ligaments 
and  soft  structures,  or  deficiency  in  the  conformation  of  the  bone- 
extremities. 

Cases  are  seen  in  which  a  joint  may  be  dislocated  in  varying  degrees,  and  this  aptitude 
may  be  cultivated  even  by  particularly  powerful  subjects,  the  ligaments  elongating  as  the 
result  of  graduated  strain. 

Pathology. — The  all-important  feature  in  dislocation  lies  in  the 
injury  to  the  capsule.  The  position  of  the  rent  determines  in  great 
measure  the  direction  taken  by  the  displaced  bone,  while  upon  its 
extent  depends  the  distance  to  which  the  bone  may  travel,  the  intact 
portion  of  the  capsule  being  the  main  check  to  the  passage  of  the 
bone  into  other  than  typical  positions.  Again,  a  small  rent  in  the 
capsule  may  be  the  chief  obstacle  to  reduction  in  difficult  cases,  while 
very  free  laceration  may  result  in  difficulty  in  maintaining  the  replaced 
bone  in  position.  The  direction  of  the  rent  may  be  oblique  in  the  axis 
of  the  joint,  or  it  may  be  transverse  to  this  axis.  In  the  latter  case,  it 
usually  lies  near  to  the  surface  of  the  bone  which  forms  the  cavity ;  in 
the  former  case,  it  often  occurs  at  a  definitely  weak  portion  of  the 
capsule,  such  as  the  under  and  inner  portions  of  the  ligament  in  the 
hip-  and  shoulder-joints. 

Certain  portions  of  the  capsules  are  very  rarely  torn.  These 
usually  correspond  to  definite  strengthening  bands,  such  as  the  ilio- 
femoral of  the  hip  or  the  coracohumeral  of  the  shoulder.  The  escape 
of  these  bands  from  injury,  of  course,  depends  chiefly  on  their  intrinsic 
strength,  and  its  importance  cannot  be  overestimated,  since  upon  their 
limiting  influence  depends  the  position  taken  up  by  the  displaced  bone, 
a  point  amply  proven  by  the  experience  gained  in  producing  the  various 
dislocations  experimentally  on  the  dead  body.  When  the  capsule  is 
completely  rent,  one  of  the  so-called  atypical  positions  is  the  result. 
While  removing  from  the  muscles  the  function  of  determining  the 
position  taken  up  by  the  displaced  bone,  we  must  none  the  less  bear 
in  mind  that  the  rigid  contraction  which  takes  place  to  maintain  the 
parts  at  rest  and  relieve  pressure-pain  forms  one  of  the  main  obstacles 
to  reduction. 


606  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Beyond  the  injury  to  the  joint-capsule,  varying  degrees  of  laceration 
may  occur  in  the  several  soft  structures  surrounding  the  articulation,  or 
even  fracture  of  the  bones  themselves.  The  more  common  forms  of 
injury  to  the  soft  parts  consist  in  more  or  less  contusion  and  ecchy- 
mosis  of  the  skin,  this  being  the  more  marked  when  the  injury  is  due 
to  direct  violence ;  in  contusion  and  laceration  of  the  subcutaneous  and 
deeper  planes  of  connective  tissue ;  in  contusion  and  laceration  of  the 
muscles,  and  rupture  or  separation  of  tendons  from  their  attachments. 
Less  commonly,  dislocation  may  be  complicated  by  pressure,  contusion, 
or  rupture  of  the  main  artery  or  vein  of  the  limb  or  one  of  their  large 
branches.  The  accidents,  with  their  attendant  risks,  will  be  again 
referred  to  under  the  heading  of  those  special  dislocations  in  which 
they  are  most  commonly  met  with.  They  may  be  followed  by  gan- 
grene of  the  limb,  death  from  internal  hemorrhage,  the  development 
of  traumatic  aneurysm,  or  thrombosis. 

Injuries  to  nerves  are  comparatively  rare.  They  may  be  followed  by 
more  or  less  permanent  paralysis,  according  to  whether  the  nerve  has 
been  contused,  suffers  permanent  pressure,  is  stretched,  or  has  been 
completely  ruptured.  Again,  primary  injury  of  the  nerve  may  be  fol- 
lowed by  the  development  of  secondary  neuritis,  producing  similar 
symptoms. 

The  commonest  form  of  injury  to  the  bones  is  the  so-called  "fract- 
ure par  arrachement "  of  Maisonneuve.  In  this  the  portion  of  bone  to 
which  a  ligament  is  attached  is  separated,  or  one  or  more  of  the  bony 
prominences  in  connection  with  the  joint  is  torn  off  by  the  tendon 
inserted  into  it.  A  less  common  form  is  that  in  which  a  portion  of  the 
margin  of  an  articular  cavity  is  broken  off  or  the  floor  of  the  cavity 
perforated.  Beyond  these  intrinsic  injuries,  a  distant  fracture  of  one  of 
the  bones  entering  into  the  articulation,  or  one  adjacent  to  it,  may  be 
caused  by  the  same  violence. 

Lastly,  a  dislocation  of  one  of  the  bones  of  the  trunk  may  be  com- 
plicated by  injury  to  the  neighboring  viscera.  Thus,  the  sternal  end  of 
the  clavicle  occasionally  presses  on  the  trachea,  or  a  dislocated  vertebra 
on  the  spinal  cord. 

The  occurrence  of  a  dislocation  is  always  followed  by  the  develop- 
ment of  a  certain  degree  of  synovial  effusion,  the  synovia  being  more 
or  less  abundantly  mixed  with  blood.  Such  effusion  is  usually  quickly 
absorbed,  but  it  may  occasionally  be  very  abundant — a  matter  of  some 
importance,  as  it  may  facilitate  the  recurrence  of  a  reduced  dislocation, 
if  proper  means  are  not  taken  to  keep  the  bones  in  position.  The  blood 
effused  into  the  surrounding  tissues  is  also  usually  rapidly  reabsorbed. 
It  serves  also  as  a  basis  for  the  development  of  the  cicatricial  tissue 
necessary  for  repair  of  the  capsule  and  other  damaged  structures. 
The  rent  in  the  capsule  is,  however,  closed  by  tissue  far  weaker  than 
the  normal  ligament,  more  capable  of  distention,  and  more  liable  to 
rupture  on  comparatively  slight  strain  ;  hence  the  importance  of  pre- 
vious dislocation  in  the  event  of  future  injury.  The  torn  muscles  and 
tendons  heal,  but  when  the  latter  have  torn  away  pieces  of  bone 
with  them,  the  repair  of  the  fracture  is  seldom  exact.  This  may 
lead  to  serious  subsequent  limitation  of  the  range  of  movement  of 
the  joint. 


DISLOCATION   OF  JOINTS.  607 

Signs  and  Symptoms  of  Dislocation. — These  are  most  con- 
veniently divided  into  classes  :  1 .  Those  visible  on  inspection  ;  2.  Those 
to  be  determined  on  palpation  and  manipulation  ;  3.  Those  dependent 
on  interference  with  function  of  the  joint  and  pressure  by  the  displaced 
bone  on  surrounding  structures. 

Inspection. — By  this  is  determined  the  general  position  of  the 
member,  alterations  of  contour,  the  projection  of  certain  bony  promi- 
nences and  the  absence  of  others,  and,  finally,  apparent  alterations  in 
the  length  of  the  limb,  which  may  be  substantiated  or  otherwise  by 
actual  measurement. 

Palpation. — By  this  is  ascertained  the  altered  relation  of  various 
fixed  bony  points,  and  the  recognition  of  those  which  are  unduly 
prominent ;  in  addition  to  this  is  determined  the  absence  of  others  from 
their  normal  positions,  often  accompanied  by  a  feeling  of  "  hollow  ten- 
sion "  of  the  investing  soft  parts  and  the  presence  of  the  displaced  bone 
in  an  abnormal  position. 

Interference  with  Function. — This  is  determined  by  first  asking 
the  patient  to  perform  certain  movements  voluntarily,  and  then  making 
similar  ones  passively,  thus  estimating  how  far  the  normal  functions  are 
limited,  and  in  what  directions. 

To  the  signs  above  enumerated  we  may  add  the  existence  of  pain, 
much  exaggerated  by  movement,  especially  marked  where  nerve-trunks 
are  pressed  upon,  and  sometimes  special  symptoms  due  to  the  pressure 
of  the  displaced  bone  on  the  vessels  or  neighboring  viscera.  Lastly,  it 
must  be  borne  in  mind  that  all  the  usual  signs  may  be  more  or  less 
obscured  by  swelling  due  to  contusion  and  local  injury. 

Diagnosis. — From  Contusion  or  Sprain. — It  suffices  here  to  say 
that  all  the  definite  signs  of  dislocation  are  absent ;  but  that,  on  the 
other  hand,  the  nature  of  the  injury  suffered,  the  pain,  swelling,  and 
interference  with  function  may  suggest  the  possibility  of  its  presence. 
In  such  cases  the  first  step  is  the  careful  exclusion  of  all  signs,  and  if 
doubt  still  exists,  the  administration  of  an  anesthetic,  which  will  clear 
up  all  chance  of  error.  In  such  cases  too  much  care  cannot  be  given 
to  the  inspection  of  the  case,  the  patient  being  sufficiently  uncovered  to 
allow  a  thorough  comparison  to  be  made  with  the  corresponding  part 
on  the  other  side  of  the  body. 

From  Fracture. — As  to  the  broad  distinctions,  it  should  be  remem- 
bered that  in  dislocation  the  normal  range  of  movements  is  limited, 
while  slight  mobility  in  abnormal  directions  may  be  present ;  in  fracture, 
the  mobility  is  increased.  In  dislocation  the  deformity,  if  removed,  does 
not  return  ;  in  fracture  it  does.  The  deformity  of  the  limb  in  disloca- 
tion is  not  so  evidently  the  result  of  the  action  of  gravity  as  in  fracture. 
Pain  is,  generally  speaking,  more  widely  diffused  in  dislocation,  more 
localized  in  fracture.  Beyond  this,  the  cardinal  symptom  of  fracture — 
"  crepitation  " — is  usually  absent  in  dislocation. 

From  Pathological  Conditions. — Infantile  paralysis  or  certain  myo- 
pathic conditions  may  apparently  simulate  dislocation.  As  a  general 
rule,  however  they  are  readily  to  be  discriminated  by  attention  to  two 
points — the  condition  of  the  muscles  which  are  atrophied  and  often 
shortened,  and  the  fact  that  the  displaced  articular  end  can  be  replaced 
with  ease,  and  when  released  returns  to  its  former  position.     From  con- 


608  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

genital  dislocation,  the  discrimination  will  depend  on  the  history,  the 
deficient  development  of  the  joint-ends  and  of  the  limb  generally.  The 
spontaneous  displacements  due  to  habitual  malposition  closely  resemble 
the  ordinary  variety,  the  history  alone  being  here  of  diagnostic  impor- 
tance. Pathological  dislocations,  although  closely  following  the  type, 
generally  offer  little  diagnostic  trouble,  if  the  history  is  carefully  taken. 
The  only  real  difficulty  occurs  in  the  case  of  joints  affected  with  osteo- 
arthritis. Patients  affected  with  this  disease  often  suffer  little  until  the 
pathological  changes  are  fairly  advanced,  in  which  case  an  injury,  by 
aggravating  their  symptoms,  first  brings  the  joint  under  notice.  Atten- 
tion to  the  absence  of  the  typical  signs  of  dislocation,  and  the  presence 
of  other  bony  changes  than  those  which  give  the  appearance  of  dislo- 
cation, together  with  the  condition  of  the  synovial  membrane  and 
muscles,  will  here  be  our  most  important  aids. 

When  available,  the  employment  of  the  A'- rays  is  an  invaluable  diagnostic  aid,  especially 
in  the  smaller  joints.  With  these  not  only  the  position  and  extent  of  dislocation  can  be 
determined,  but  also  the  presence  or  absence  of  coexistent  fracture.  If  a  fluorescent  screen 
is  at  hand,  this  is  by  far  the  preferable  method,  as  the  joint  can  be  examined  both  before 
and  after  manipulations  for  reduction.  Where  a  skiagram  is  taken,  at  least  two  positions 
should  be  tried,  usually  a  lateral  and  an  anteroposterior  one  ;  and  great  care  is  necessary  to 
prevent  the  occurrence  of  a  distorted  image  due  to  a  want  of  parallelism  of  the  plate  and 
the  limb  and  proper  horizontal  passage  of  the  rays.  If  these  precautions  are  not  taken,  a 
very  confusing  and  unreliable  result  is  often  obtained.  If  necessary,  a  subsequent  skiagram 
is  readily  taken  without  the  removal  of  the  splint  and  bandages. 

Prognosis. — No  dislocation  in  itself,  unless  compound  or  com- 
plicated, can  be  said  to  be  dangerous  to  life.  The  question  of  prog- 
nosis, therefore,  mainly  concerns — first,  the  possibility  of  reduction ; 
second,  the  maintenance  of  the  displaced  bone  in  position ;  and  third, 
•  the  persistence  of  after-effects. 

As  to  the  first  point,  recent  dislocations  comparatively  rarely  prove 
impossible  of  reduction.  Occasionally,  however,  all  efforts  are  fruitless, 
and  under  these  circumstances,  failing  operative  measures,  all  that  can 
be  done  is  to  try  and  ensure  as  free  movement  of  the  bone  as  possible 
in  its  new  position. 

Proper  precautions  rarely  fail  to  ensure  the  maintenance  of  the 
replaced  bone ;  but  it  is  well  to  bear  in  mind  that  especial  care  is 
necessary  to  render  the  patient  safe  from  this  accident,  if  there  is 
reason  to  believe  that  the  capsule  has  been  extensively  lacerated,  or 
if  the  injury  is  the  cause  of  very  free  effusion  into  the  joint. 

The  first  after-effect,  the  occurrence  of  synovitis,  is  seldom  of  any  great  importance 
except  as  taking  its  part  in  the  production  of  the  commonest  of  all  troubles,  a  greater  or  less 
degree  of  stiffness,  due  to  the  formation  of  synovial  adhesions,  and  the  contraction  of  the 
cicatricial  tissue  formed  in  the  process  of  healing  of  the  original  injur)'.  These  troubles, 
however,  in  the  absence  of  unusually  severe  primary  damage,  are  generally  to  be  obviated 
by  the  sufficiently  early  employment  of  passive  movements,  combined  with  massage.  Stiff- 
ness and  loss  of  function  are  necessarily  much  more  frequent  and  troublesome  to  deal  with 
if  the  dislocation  is  complicated  with  an  hysterical  temperament  or  actual  injury  to  the  nerve- 
trunks. 

The  most  serious  after-effect  is  the  acquisition  of  a  tendency  to  recurrence.  The  com- 
monest cause  of  this  is  the  stretching  of  the  cicatricial  tissue  which  closes  the  capsular  rent, 
and  as  evidence  of  this,  it  has  been  generally  found,  when  opportunity  has  arisen,  either  in 
the  course  of  an  operation  or  post-mortem  examination,  that  the  capsule  is  considerably 
wider  and  more  roomy  than  normal.  Unfortunately,  this  is  an  inevitable  result  in  the  case 
of  many  working  men,  but  none  the  less  it  should  impress  the  importance  of  careful  regula- 
tion of  the  amount  of  work  that  is  undertaken  by  the  patient  during  the  first  few  months 


DISLOCATION  OF  JOINTS.  609 

after  the  original  injury.  In  other  cases  recurrence  depends  on  causes  over  which  we  have 
little  or  no  control,  and  among  these  may  be  especially  mentioned  very  extensive  or  complete 
ruptures  of  the  capsule,  and  the  failure  of  fragments  of  bone  to  unite  when  they  are  torn  off 
by  the  tendons  in  the  so-called  "  fractures  par  arrachement. " 

The  question  of  compound  and  old  dislocations  will  be  considered 
at  the  end  of  this  chapter. 

Treatment. — The  treatment  of  dislocation  necessarily  consists  in 
its  reduction.  For  the  attainment  of  this  end,  several  methods  are 
open  to  us.  The  most  important  of  all  rules  for  the  treatment  of  these 
injuries  is  that  a  dislocation  of  any  bone  should  be  returned  by  the 
method  that  necessitates  the  least  possible  force,  and  hence  the  least 
possible  chance  of  further  lacerating  the  already  damaged  structures. 

The  method  always  to  be  tried  first,  therefore,  is  the  gentle  correc- 
tion of  the  false  position  assumed  by  the  displaced  bone,  combined  with 
slight  traction  in  its  axis,  and  possibly  movements  of  internal  or  exter- 
nal rotation.  Failing  this  method,  we  have  manipulation-maneuvers 
and  extension  to  fall  back  upon.  Of  these,  manipulation  is  the  more 
scientific,  since,  especially  in  the  case  of  the  hip-  and  shoulder-joints, 
the  methods  are  founded  on  an  accurate  knowledge  of  the  injury  proba- 
bly existing  and  of  the  structures  which  remain  intact.  The  theory  of 
the  manipulation-methods  is — first,  to  lift  the  displaced  articular  extrem- 
ity from  its  false  position  by  employing  an  intact  part  of  the  capsule  as 
a  fulcrum  ;  second,  by  rotatory  movements  to  ensure  the  gaping  of  the 
rent  in  the  capsule  ;  third,  to  bring  the  articular  end  opposite  the  rent ; 
and  lastly,  by  a  reversal  of  the  movement,  to  effect  the  entrance  of  the 
displaced  bone  into  its  proper  position.  In  the  whole  maneuver  the 
shaft  of  the  displaced  bone  is  used  as  a  lever,  and  the  power  of  this 
will  necessarily  vary  with  the  length  of  the  bone  in  question. 

The  extension-methods  consist  in  a  preliminary  fixation  of  the  trunk 
or  proximal  element  of  the  joint,  followed  by  traction  made  in  the  axis 
of  the  displaced  bone,  the  latter  also  being  usually  utilized  as  a  lever, 
the  fulcrum  for  which  is  furnished  by  a  ligament  or  bony  prominence, 
or  is  artificially  provided.  A  sufficient  degree  of  counterextension  is 
obviously  necessary.  The  traction  may  be  manual  or,  if  necessary, 
exerted  by  pulleys.  All  these  methods  will  be  more  fully  dealt  with 
under  the  heading  of  the  Special  Joints. 

The  after-treatment  consists  in  rest  for  a  variable  period,  followed 
by  massage  and  exercises.  The  rest  may  be  obtained  by  splints,  band- 
ages, or  the  arrangement  of  permanent  extension-apparatus  in  cases 
where  splints  prove  inefficient. 

Signs  of  Reduction. — The  effectual  reduction  of  a  dislocation  is 
usually  indicated  by  something  in  the  way  of  a  snap,  accompanied  by 
a  sensation  of  grating  felt  by  the  surgeon  as  the  bones  resume  their 
normal  relation.  Beyond  this  the  injured  part  should  more  or  less 
resume  its  proper  outline,  corresponding  to  that  of  the  other  side  of  the 
body,  the  possibility  of  performing  passive  movements  should  be  per- 
fect, and,  most  important  of  all,  the  relation  of  the  bony  points  in  the 
neighborhood  should  not  deviate  from  the  normal. 

Obstacles  to  Reduction. — Although  responsible  in  a  minor  degree 
only  for  the  position  assumed  by  the  displaced  bone,  yet  the  muscles, 
by  their  contraction,  often  offer  a  decided  obstacle  to  reduction.  This 
39 


6lO  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

is  to  be  removed  at  once  by  the  use  of  an  anesthetic,  and  needs  no 
further  mention. 

A  more  formidable  obstacle,  however,  may  exist  in  the  disposition 
of  the  rent  in  the  capsule.  This  may  be  unusually  small  and  run  in  an 
atypical  direction,  or,  on  the  other  hand.it  may  be  so  extensively  lacer- 
ated as  to  remove  our  main  aid  in  reduction  by  manipulation — viz.,  the 
intact  portion  which  is  employed  to  act  as  a  fulcrum.  Beyond  this, 
portions  of  the  capsule  may  take  up  a  position  across  the  joint-cavity ; 
a  similar  position  may  be  taken  by  a  neighboring  muscle  or  tendon,  or 
a  bony  fragment. 

A  small  rent  may  be  enlarged  by  cautious  manipulation,  and  a  rent 
in  an  unusual  position  may  be  found  by  varying  our  method  of  manipu- 
lation. When  wide  destruction  of  the  capsule  is  the  difficulty,  exten- 
sion will  probably  be  the  best  method  to  try ;  and  we  must  remember 
here  that  if  successful,  care  must  be  exercised  to  maintain  the  bones  in 
their  proper  position  when  reduced.  The  interposition  of  torn  struct- 
ures is  hardly  to  be  met  by  any  general  rule ;  we  can  only  bear  in 
mind  the  many  variations  in  procedure  open  to  us,  and  make  use  of 
them  successively.  Operative  methods  may  become  necessary  if  the 
dislocation  cannot  be  reduced,  or,  in  some  joints,  when  reduction  can- 
not be  maintained. 

Occasionally,  subcutaneous  division  of  obstructing  bands  will  suffice  ;  more  often  an 
open  incision  is  necessary,  and  in  a  small  proportion  of  cases  excision,  either  partial  or 
complete,  has  to  be  resorted  to.  Recurrent  dislocation  may  be  treated  by  temporary  suture 
of  the  opposing  joint-surfaces.  These  methods  will  be  more  particularly  referred  to  under 
the  special  joints  ;  but  it  may  be  broadly  stated  that  in  certain  joints  operative  measures 
will  not  improve  the  result  to  be  obtained  by  careful  after-treatment,  and  that  in  all  a  careful 
consideration  of  the  local  conditions,  as  well  as  of  the  age,  occupation,  and  general  condi- 
tion of  the  patient,  must  precede  a  determination  to  resort  to  them. 

One  other  difficulty  should  here  find  mention — the  simultaneous  fracture  of  the  dislocated 
bone  in  the  immediate  region  of  the  joint.  This  occurrence,  though  fortunately  far  from 
common,  affords  one  of  the  most  difficult  problems  in  surgery.  Several  alternatives  are 
open  to  us.  We  may  put  up  the  fracture  and  wait  for  its  consolidation  before  attempting 
reduction.  This,  as  necessitating  a  delay  of  some  weeks,  is  most  unsatisfactory,  since  we 
must  either  wait  until  the  chance  of  reducing  the  dislocation  is  problematic,  or  risk  the 
chance  of  re-fracture  without  succeeding  in  reinstating  the  bone  in  the  joint.  The  immedi- 
ate application  of  splints  and  attempts  at  reduction  have  rarely  been  successful,  unless  the 
fracture  is  at  some  distance  from  the  joint.  Lastly,  we  have  the  open  method  of  replacing 
the  bone  by  incision  of  the  joint  and  simultaneous  wiring  of  the  fractured  ends.  Given  a 
sufficiently  young  and  healthy  subject  with  good  surroundings,  there  is  little  doubt  that  the 
last  is  the  best  method  ;  but,  if  undertaken,  it  should  be  remembered  that  the  operation  is 
often  one  of  extreme  difficulty,  and  necessitates  the  most  scrupulous  care  if  it  is  not  to  lead 
to  disaster. 

Compound  Dislocation. — This  accident  is  fortunately  a  rare  one, 
and  still  more  so  if  uncomplicated  by  fracture.  It  is  most  common  in 
the  small  joints  of  the  hands  and  foot  and  in  the  elbow. 

As  is  the  case  with  compound  fracture,  the  nature  of  the  injury 
varies  with  that  of  the  violence  exerted,  displacement  produced  by 
direct  violence  being  usually  accompanied  by  the  more  severe  local 
injury.  Dislocation  is,  however,  the  more  serious,  as  in  addition  to  a 
contused  wound  we  have  a  synovial  cavity  laid  open,  often  at  the  least 
favorable  aspect  for  the  establishment  of  efficient  drainage.  As  in  fract- 
ure, a  conservative  line  of  treatment  is  to  be  adopted,  bearing  in  mind 
the  increased  severity  of  the  case  and  the  smaller  likelihood  of  avoiding 
suppuration.     While  a  purely  conservative  line  of  treatment  is  best, 


DISLOCATION   OF  JOINTS.  6ll 

excision  or  partial  excision  is  in  many  cases  indicated  as  promising 
the  best  chance  of  obtaining  a  satisfactory  result. 

Old  Dislocations. — A  certain  number  of  dislocations  remain  un- 
reduced. This  failure  to  secure  reduction  may  depend  on  omission  to 
recognize  the  nature  of  the  accident  on  the  part  of  the  medical  attend- 
ant, on  neglect  of  the  injury  on  the  part  of  the  patient,  or,  more  rarely, 
on  some  of  the  obstacles  to  reduction  (already  enumerated)  proving 
insurmountable.  If  for  any  of  these  reasons  the  bone  remains  in  its 
new  position,  certain  pathological  consequences  result,  with  the  effect 
of  compensating  to  a  certain  extent  for  the  interference  with  function 
attendant  on  the  injury.     In  the  first  place,  the  soft  tissues  around  the 


Fig.  297. — Old  dislocation  of  humerus;  bony  change  (St.  Thomas's  Museum,  London). 

articulation  become  consolidated  by  the  cicatrization  of  the  parts 
injured,  and  in  this  way  a  new  joint-capsule  is  developed.  With  the 
lapse  of  time,  this  capsule  gains  consistency,  besides  firm  attachment  to 
the  bones,  and  may  become  provided  with  an  adventitious  synovial 
lining.  Meanwhile,  certain  changes  take  place  in  the  osseous  elements. 
The  irritation  caused  by  the  pressure  of  the  displaced  bone  leads  to  the 
development  from  the  periosteum  of  a  circumferential  ring  of  new  bone, 
which  moulds  itself  to  the  outline  of  the  articular  extremity  much  as 
the  circumferential  margins  of  the  joint-cavities  are  originally  devel- 
oped, or  as  a  new  cavity  is  seen  to  develop  in  the  pathological  disloca- 
tions of  the  hip  with  the  so-called  wandering  acetabulum. 

The  cavity  may  reach  a  high  degree  of  development,  the  bone  acquiring  a  thick,  fibrous 
investment  representing  the  normal  cartilaginous  covering.  In  other  cases,  especially  in 
old  persons,  the  bone  becomes  smooth  and  eburnated,  as  in  joints  affected  with  chronic 
traumatic  arthritis.  The  moulding  of  the  new  cavity  is  mainly  dependent  on  the  new  bony 
formation  ;  but  it  depends  in  part  also  on  pressure-atrophy,  as  is  proved  by  the  pressure- 
changes  which  occur  in  the  displaced  bone  when  it  is  a  prominent  articular  head,  like  the 
humerus.  A  glance  at  the  illustration  of  an  old  dislocation  (Fig.  297),  exhibiting  in  the 
anatomical  neck  a  deep  groove  corresponding  to  the  point  at  which  it  rested  against  the 
margin  of  the  glenoid  cavity,  well   demonstrates  this  point,  even  when  the  comparatively 


6l2  TNTERNATIONAL     TEXT-BOOK  OF  SURGERY. 

cancellous  nature  of  this  element  of  the  joint  is  allowed  for.  Gradually,  with  the  develop- 
ment of  the  new  joint,  obliterative  changes  proceed  in  the  old  one,  or  in  the  parts  of  it  no 
longer  functional.  The  matrix  oi  the  cartilage  becomes  fibrillated,  and  gradually  blends 
with  new  fibrous  tissue  developed  in  part  from  old  joint  elements,  such  .1-  Strips  of  capsule, 
in  part  from  inflammatory  new-formation.  A  consideration  of  these  changes  demonstrates 
to  us  the  difficulty  likely  to  attend  the  attempted  reduction  of  an  old  dislocation  of  anything 
more  than  six  weeks'  duration;  but  at  the  same  lime  it  must  be  home  in  mind  that  the 
rapidity  with  which  they  occur  in  different  individuals  varies  greatly. 

The  diagnosis  and  prognosis  in  old  dislocations  will  be  considered 
under  the  accounts  of  the  special  joints.  As  to  treatment,  it  is  only 
necessary  to  point  out  here  that  we  have  two  courses  open  to  us,  sup- 
posing reduction  to  be  either  impracticable  or  inexpedient — either  to 
do  our  best  by  the  employment  of  adequate  passive  movement  and 
massage  to  promote  the  formation  of  a  new  movable  joint,  or  to  have 
recourse  to  operative  measures. 

In   attempts  at   reduction  the  more  forcible   methods  of  extension 


I    .  ^    J 

FIG.  298. — Skiagraph  of  fracture-dislocation  of  elbow    to  illustrate    the    employment  of   the 
X-rays  to  a  limb  enveloped  by  splints  and  bandages  (skiagraph  by  A.  B.  Blacker). 

and  manipulation  have  usually  to  be  employed ;  and  these  are  the 
more  likely  to  be  successful  if,  as  a  preliminary,  the  movements  have 
been  rendered  as  free  as  possible  by  forcible  manipulation,  in  order 
that  adventitious  adhesions   may  be  broken  down. 

If  bloodless  methods  fail,  success  may  be  attained  by  subcutaneous  division  of  tendons, 
ligaments,  or  other  tense  bands  ;  in  other  cases  it  may  be  as  well  to  proceed  at  once  to  open 
arthrotomy  or  to  resection.  If  the  former  is  selected,  it  should  be  borne  in  mind  that  the 
difficulties  preventing  reduction  by  ordinary  methods  may  render  reduction  after  incision 
equally  impossible.  Hence  we  should,  as  a  rule,  be  prepared  to  proceed  to  the  more 
serious  operation  at  the  first  failure.  Resection  of  the  joint  is  most  commonly  indicated 
when  the  ankylosis  is  more  or  less  complete,  or  when  the  displaced  bone  gives  rise  to  severe 
pressure-symptoms.  In  some  cases,  a  partial  resection  will  suffice,  by  removing  a  prominent 
process  of  bone,  which  has  been  the  most  serious  obstacle  to  free  movement ;  in  others,  the 
resection  will  need  to  be  a  very  free  one,  in  order  to  avoid  subsequent  ankylosis.  Free 
resection  is  especially  indicated  in  fracture  with  dislocation,  as  of  the  elbow,  where  the 
development  of  abundant  callus  has  already  been  an  important  element. 

Accidents  during  reduction  and  complications  are  the  same  in  nature,  after  attempts  to 
reduce  old,  as  recent  dislocations  ;  but  it  should  be  borne  in  mind  that  attempts  at  reduction 
of  old  dislocations  have  given  us  the  richest  experience  of  these  complications.  Therefore, 
while  employing  sufficiently  forcible  measures,  very  great  care  must  be  taken  to  adapt  the 
loir,    used   to  the  powers  of  resistance  of  each   particular  case. 


SPECIAL    DISLOCATIONS.  613 

Pathological  Dislocations. — These  may  be  due  to  a  variety  of 
causes,  such  as  excessive  effusion  into  the  joint-capsule,  weakening  or 
absorption  of  the  ligaments  as  the  result  of  inflammatory  changes  of 
various  kinds,  or  relaxation  of  the  ligaments  as  a  result  of  shortening  or 
distortion  of  the  intra-articular  portion  of  the  bone,  secondary  to  disease. 
Allied  in  nature  to  this  form  are  the  displacements  occasionally  seen  as 
the  result  of  habitual  malposition  in  the  very  weak  or  in  the  insane.  The 
articular  end  of  the  bone  here  presses  locally  on  a  capsule  deficient  in 
tone,  which  gradually,  or  sometimes  suddenly,  gives  way  and  allows 
the  development  of  a  typical  dislocation.  The  early  recognition  of 
the  latter  displacements  is  the  more  important  in  that  they  are  often 
capable  of  reposition  and  cure. 

SPECIAL  DISLOCATIONS. 

Lower  Jaw. — Situated  at  some  depth  from  the  surface  and  over- 
hung by  the  zygomatic  arch,  the  temporomaxillary  joint  is  well  pro- 
tected from  direct  violence ;  but  the  body  of  the  jaw  and  its  ramus 
form  a  bar  of  considerable  length,  which,  acted  on  by  indirect  violence 
applied  to  the  body-angle  or  symphysis,  may  exert  powerful  leverage 
on  the  structures  retaining  the  condyle  in  position,  and  may  lead  to 
dislocation.  This  joint  is  the  articulation  of  all  others  prone  to  dis- 
placement from  muscular  action — a  fact  readily  explained  when  we 
remember  that  the  simple  action  of  opening  the  mouth  may  be  almost 
regarded  as  a  subluxation  of  the  condyle  which  a  very  slight  increase 
in  range  may  convert  into  an  actual  dislocation. 

Certain  conditions  specially  favor  the  possibility  of  dislocation.  1.  With  the  mouth 
closed  the  condyles  rest  in  the  hollow  of  the  glenoid  cavity,  but  when  open,  on  the  convex 
eminentia  articularis.  2.  The  capsule  has  to  be  very  loose  to  allow  of  the  inclusion  of  the 
large  eminentia  articularis,  and,  besides,  it  is  weak,  the  only  strong  band,  the  external  lateral 
ligament,  being  sloped  downward  and  backward  to  allow  the  forward  gliding  of  the  jaw 
when  the  mouth  is  open.  The  small  part  taken  by  the  capsule  in  resisting  dislocation  is 
evidenced  by  the  fact  that  it  is  never  torn  when  this  occurs.  3.  The  large  fibrocartilage 
necessary  for  the  adaptation  of  the  bony  surfaces  is  provided  anteriorly  with  a  powerful 
insertion  of  the  external  pterygoid  muscle. 

The  normal  stability  of  the  joint  is  well  shown  by  the  fact  that  dis- 
locations are  only  common  at  an  age  in  which  retrogressive  changes 
have  led  to  manifest  alterations  in  both  the  form  and  direction  of  the 
condyle  and  the  depth  of  the  alveolus. 

Frequency  of  Occurrence. — In  the  St.  Thomas's  series  of  1207  dis- 
locations, 42  dislocations  of  the  mandible  occurred,  being  3.47  percent, 
of  the  whole  number.  In  Kronlein's  series  10  were  observed  in  a  total 
of  400 — that  is  to  say,  2.5  per  cent. 

Causation  and  Classification. — Luxations  are  most  frequent  as  the 
result  of  a  too  extensive  movement  of  the  jaw  in  the  acts  of  laughing 
or  yawning,  and  therefore  are  mostly  due  to  muscular  action.  They 
are  more  common  in  women.  Dislocation  may,  however,  be  produced 
in  a  precisely  similar  manner  by  violent  manipulation  in  extracting 
teeth,  introducing  a  gag  or  instrument  into  the  mouth,  or,  more  rarely, 
by  blows  while  the  mouth  is  open.  The  displacement  may  be  unilat- 
eral or  bilateral.  In  the  St.  Thomas's  statistics,  21  were  bilateral,  4 
were  of  the  right  condyle,  9  of  the  left.     In  8  the  variety  is  not  stated. 


614 


INTERNATIONAL    TEXTBOOK  OE  SURGERY. 


Pathology. — When  displaced,  the  condyles  pass  forward  into  the  zygomatic  fossa,  and 
remarkably  little  laceration  of  the  structures  occurs  except  of  the  loose  tissues  surrounding 
the  joint,  even  the  capsule  remaining  intact.  Difficulty  in  reduction  has  been  ascribed  to 
locking  of  the  coronoid  process  against  the  zygomatic  arch,  but  this  has  been  effectively 
disproved,  the  difficulty  in  recent  cases  depending  on  muscular  contraction,  in  old  cases  on 
adhesions. 

Symptoms. — Bilateral  Dislocation. — On  inspection,  the  mouth 
stands  fixedly  open,  and  although  the  jaw  can  often  be  somewhat 
depressed,  all  attempts  at  closure  fail.  In  thin  faces  the  swelling  of  the 
condyle  at  an  anterior  position  is  often  evident,  and  the  contracted  tem- 
poral and  masseter  muscles  form  prominences  above  and  below  the 
zygoma.  On  palpation,  a  hollow  can  be  felt  anterior  to  the  ear  in  the 
usual  position  of  the  condyle  and  posterior  to  the  prominence  already 
noted.  On  palpation  from  within  the  mouth,  the  coronoid  process  may 
be  felt  in  an  advanced    position.     There  is  much    local    pain  due  to 


Fig.  299. — Bilateral  dislocation  of  the  jaw. 

stretching  and  pressure  on  the  branches  of  the  third  division  of  the  fifth 
nerve,  which  may  radiate  to  the  ear  and  scalp ;  saliva  dribbles  from  the 
mouth,  as  a  result  of  pressure  on  the  salivary  glands.  The  patient  is 
unable  to  masticate,  and  the  speech  is  defective. 

Unilateral  Dislocation. — In  this  variety  the  signs  are  similar,  but 
they  are  confined  to  one  side,  and  consequently  less  pronounced.  The 
mouth  is  less  widely  open,  and  the  distortion  is  asymmetrical  from  the 
pushing  of  the  symphysis  to  the  opposite  side.  On  the  other  hand, 
diagnostic  advantage  is  gained  in  having  the  sound  side  for  the  pur- 
poses of  comparison. 

Compound  dislocations  are  uncommon,  and  are  always  due  to  direct 
wounds  over  the  temporomaxillary  joint. 

Prognosis. — The  reduction  of  recent  displacements  is  usually  easy 
enough,  but  if  the  injury  is  overlooked,  the  symptoms  gradually 
become  less  marked,  and  mobility  increases  so  as  to  allow  of  a  modi- 
fied use  of  the  jaw.     After  a  lapse  of  three  months,  there  is  not  much 


SPECIAL    DISL  OCA  TWXS. 


6l5 


likelihood  of  successful  reduction,  but  an  attempt  should  certainly  be 
made  up  to  the  expiration  of  six  months.  The  most  important  point 
prognostically  is  the  acquisition  of  a  marked  tendency  to  recurrence 
on  very  slight  provocation. 

Diagnosis. — Confusion  with  any  other  condition  is   unlikely,  since 
the  change  in  the  patient's  appearance  is 
so  sudden  that  hardly  any  other  expla- 
nation would  meet  the  conditions  of  the 
case. 

Treatment. — Pressure  being  made  on, 
or  in  the  position  of,  the  last  molar  teeth 
by  the  thumbs  of  the  surgeon  (carefully 
wrapped  around  with  a  cloth  for  protec- 
tion), a  fulcrum  situated  below  the  nor- 
mal center  of  motion  is  furnished  for  the 
depressed  angle  by  the  masseter  and 
internal  pterygoid  muscles  and  by  the 
stylomaxillary  and  lateral  ligaments  of 
the  joint.  A  kind  of  bilateral  sling  is 
thus  provided,  in  which  the  jaw  is  suf- 
ficiently depressed  to  allow  the  condyle 
to  reach  the  most  prominent  part  of  the 
eminentia  articularis,  when  the  symphysis 
is  elevated  by  the  fingers,  and  the  jaw  is 
suddenly  drawn  back  and  slips  into  position, 
this  maneuver  can  be  carried  out  without  the  aid  of  an  anesthetic,  and 
in  many  cases  some  subjects  of  recurrent  dislocation  are  able  to  carry 
it  out  for  themselves.  Less  commonly  great  difficulty  is  experienced, 
and  an  anesthetic  may  be  necessary,  the  use  of  the  thumb-pressure 
being  often  insufficient. 

Many  mechanical  devices  in  the  way  of  wedges  and  wooden  bars  have  been  tried.  I  can 
very  warmly  recommend  a  simple  method  I  have  myself  found  successful — namely,  the  use 
of  a  pair  of  ordinary  bifid  wound-retractors.  These  should  be  sheathed  with  rubber  tubing. 
An  assistant,  standing  above  the  head  of  the  patient,  applies  one  on  either  side,  immediately 
anterior  to  the  ramus  of  the  jaw,  and  makes  firm  pressure  downward  and  backward,  while 
the  surgeon  takes  charge  of  the  patient's  chin,  raising  it  as  the  pressure  of  the  artificial 
fulcrum  is  increased. 


Fig.  3°°— Mode  of  manual 
reduction. 


In  the  majority  of  instances 


In  compound  dislocation,  the  treatment  is  to  be  carried  out  on 
general  aseptic  principles.  The  main  point  to  keep  in  mind  is  the 
possible  occurrence  of  ankylosis,  which  must  be  combated  by  allow- 
ing the  patient  to  make  free  use  of  the  jaw  as  soon  as  is  practicable. 
Should  ankylosis  occur  on  one  side  only,  it  may  not  require  special 
treatment;  if,  however,  it  is  bilateral,  one  or  both  joints  ma}'  be 
excised. 

After  reduction,  the  jaw  is  best  supported  and  held  in  position  by  a 
four-tailed  bandage,  so  applied  as  to  make  upward  and  backward  press- 
ure on  the  prominence  of  the  chin.  This  must  be  worn  three  to  four 
weeks.  The  patient  should  be  cautioned  as  to  the  need  of  future  care 
in  widely  opening  the  mouth,  and  fluid  diet  is  obligatory,  being  best 
administered  by  a  tube  passed  behind  the  last  molar,  if  the  teeth  are 
still  present. 


6l6  INTERNATIONAL    TEXT  BOOK  OF  SURGERY. 

Clavicle. — The  sternoclavicular  joint  is  peculiar  in  arrangement, 
while  its  relation  to  the  movements  of  respiration  renders  it  difficult  to 
maintain  the  constituent  bones  at  absolute  rest.  Displacement,  when 
it  occurs,  is  difficult  to  combat,  on  account  of  the  weight  of  the  depend- 
ing upper  extremity,  the  force  of  gravity  exerting  great  influence  on  the 
deformity  accompanying  this  dislocation. 

The  articulation  owes  its  security  to  the  difficulty  of  concentrating  force  directly  upon  it, 
due  to  the  curves  of  the  clavicle,  the  mobility  of  the  scapula,  and  the  play  of  the  acromio- 
clavicular joint  ;  also  to  reinforcement  of  the  capsule  by  the  tendinous  origins  of  the  sterno- 
mastoid  and  pectoral  is  major,  to  the  costoclavicular  ligament,  and  to  the  attachment  of  the 
interarticular  fibrocartilage. 

Frequency  of  Occurrence. — In  the  St.  Thomas's  series  of  1207 
dislocations,  the  sternal  end  of  the  clavicle  was  displaced  in  18  or  1.49 
per  cent.  In  Kronlein's  400,  the  displacement  occurred  in  6,  or  1.5 
per  cent. 

Causation  and  Classification. — The  accident  almost  invariably 
results  from  indirect  violence  exerted  on  the  shoulder.  It  has  been 
produced  by  muscular  action,  as  in  swimming ;  backward  displacement 
has  been  caused  by  direct  violence. 

The  bone  may  pass  in  either  of  three  directions — forward,  upward,  or  backward.  Of 
these,   the  first  is  by  far  the  most  frequent,   the  second   and  third  varieties  being  rare. 

Forward  dislocation  is  caused  by  falls  or  blows  forcing  the  shoulder  backward. 

Pathology. — The  head  of  the  bone  lies  on  the  anterior  surface  of  the  sternum,  com- 
monly a  little  below  its  normal  level,  the  chondrosternal  cavity  being  crossed  by  the  inner 
end  of  the  shaft  of  the  clavicle.  The  degree  of  displacement  varies,  and  depends  mainly 
on  the  extent  of  the  rupture  of  the  costoclavicular  ligament. 

Symptoms. — On  inspection  the  head  is  found  inclined  to  the  injured  side  ;  the  shoulder 
is  approximated  to  the  mid-line  and  falls  somewhat  backward  ;  the  hollows  of  the  posterior 
triangle  and  the  infraclavicular  fossa  are  deepened,  the  former  often  sharply  marginated 
anteriorly  by  the  outer  edge  of  the  cleidomastoid.  The  sternal  end  of  the  displaced  bone 
is  visible  as  a  prominence  over  the  sternum. 

Upward  dislocation  is  caused  by  falls  on  the  upper  and  outer  aspect  of  the  shoulder, 
leading  to  its  forcible  depression,  or  by  a  similar  movement  caused  by  dragging  on  the  arm. 

Pathology. — The  head  of  the  bone  rests  on  the  episternal  notch,  passing  to  or  beyond 
the  median  line  in  front  of  the  trachea.  The  inner  end  of  the  shaft  lies  between  the  sternal 
head  of  the  sternomastoid  and  the  sternohyoid,  and  above  the  chondrosternal  cavity. 

Symptoms. — On  inspection  the  shoulder  is  found  depressed,  approximated  to  the  mid- 
line of  the  body,  and  the  axis  of  the  clavicle  is  so  shifted  as  to  increase  the  distance  between 
the  sternal  extremity  and  the  first  costal  cartilage.  The  symmetry  of  the  line  corresponding 
with  the  inner  margin  of  the  sternomastoid  is  destroyed  by  the  presence  of  the  shaft  of  the 
clavicle  beneath  it,  and  the  suprasternal  hollow  is  obliterated  or  rendered  convex  by  the 
abnormal  presence  of  the  articular  end.  The  hollow  of  the  posterior  triangle,  and  also  the 
infraclavicular  fossa,  are  more  shallow. 

On  palpation  the  sternal  end  of  the  bone  may  be  felt,  and  the  point  of  the  finger  may 
determine  the  outline  of  the  joint-cavity,  in  the  widened  space  between  it  and  the  first  costal 
cartilage.  The  sternomastoid  of  the  corresponding  side,  or  both  muscles  are  abnormally 
tense. 

<  )n  manipulation  the  displaced  bone  may  be  reduced  by  traction  of  the  shoulders  back- 
ward, and  flexion  of  the  neck  or  raising  of  the  shoulders  may  give  rise  to  symptoms  of 
tracheal  compression.  Pressure  on  the  trachea  may  give  rise  to  severe  dyspnea,  so  great 
as  hardly  to  allow  the  patient  to  speak. 

Backward  Dislocation. — In  a  large  proportion  of  cases,  this  is  caused  by  direct 
violence  ;  but  it  may  result  from  powerful  lateral  compression  of  the  shoulders,  and  has 
been  known  to  occur  as  the   secondary  result  of  lateral  curvature  of  the  spine. 

Pathology. — The  articular  end  lies  deeply  beneath  the  sternum  and  the  origins  of  the 
sternohyoid.  It  may  sometimes  rise  above  the  level  of  the  sternum,  probably  as  a  result  of 
the  weight  of  the  arm  depressing  the  outer  end.  The  trachea  is  pushed  over  to  the  opposite 
side  of  the  neck,  the  articular  end  of  the  bone  resting  on  the  gullet.  The  subclavian  or 
innominate  vessels  may  be  subjected  to  considerable  pressure.  The  injury  to  ligaments,  etc., 
is  similar  in  nature  to  that  observed  in  the  other  forms  of  dislocation. 


SPECIAL   DISLOCATIONS.  617 

Symptoms.— The.  head  is  usually  inclined  to  the  opposite  side,  although  the  reverse  has 
been  noted.  The  margin  of  the  sternomastoid  on  the  sound  side  is  abnormally  prominent, 
the  shoulder  is  raised  and  approximated  to  the  median  line,  while  the  acromial  end  of  the 
clavicle  is  unduly  prominent.  A  hollow  exists  in  the  proper  position  of  the  articular  end 
of  the  bone,  marginated  below  by  the  sternocostal  portion  of  the  pectoralis  major.  On 
palpation,  the  outline  of  the  empty  cavity  may  be  determined,  and  when  the  interarticular 
cartilage  remains  attached  to  the  costal  cartilage,  this  has  also  been  felt.  If  the  articular 
end  of  the  bone  rises,  it  may  be  felt  above  the  sternum.  The  deformity  may  be  corrected  by 
drawing  the  shoulder  backward,  but  reduction  is  seldom  complete  and  is  difficult  to  maintain. 

Diagnosis. — The  diagnosis  of  the  different  varieties  is  readily  made  by  attention  to  the 
special  symptoms  of  each  already  detailed.  The  special  feature  is  the  recurrence  of  the  dis- 
placement when  traction  is  discontinued. 

Prognosis. — A  good  functional  result  is  the  rule,  little  permanent  disability  persisting. 
On  the  other  hand,  although  easy  of  reduction,  these  displacements  can  rarely  be  kept  in 
position,  and  more  or  less  deformity  remains. 

Treatment. — Traction  is  to  be  made  in  the  axis  of  the  displaced  bone,  the  shoulder  being 
drawn  outward  and  backward,  some  elevation  being  combined  in  the  case  of  the  upward 
dislocation  ;  for  the  permanent  correction  of  the  deformity  a  pad  should  be  placed  in  the 
axilla.  Reduction  is  best  maintained  by  the  application  of  a  plaster-of-Paris  casing  encir- 
cling both  the  arm  and  chest,  either  the  arm  being  brought  over  the  front  of  the  chest  with 
the  hand  on  the  opposite  shoulder,  or,  if  it  proves  more  satisfactory,  the  shoulder  being 
drawn  back  by  a  figure-of-8  bandage  applied  beneath  the  plaster.  In  deciding  this  matter 
we  must  be  guided  by  the  case  before  us,  as  considerable  variation  is  met  with  in  individual 
instances.  In  case  of  the  anterior  displacements,  direct  pressure  should  be  applied  to  the 
head  of  the  bone  by  means  of  a  special  strip  of  strapping  and  a  pad.  If  plaster  of  Paris  is 
not  available,  or  if  for  any  reason  it  is  inapplicable,  strips  of  strapping  or  an  ordinary 
bandage  may  be  employed.  The  displacement  may  be  treated  by  placing  the  patient  in  the 
recumbent  position  after  reduction,  in  the  posterior  variety  the  trunk  being  raised  in  such  a 
manner  as  to  allow  the  shoulder  to  fall  backward.  Great  reserve  should  always  be  exer- 
cised in  giving  assurances  to  the  patient  as  to  the  amount  of  after-deformity.  The  apparatus 
must  be  worn  at  least  five  or  six  weeks. 

Scapula. — The  acromion  process  of  the  scapula  may  be  displaced 
from  its  connection  with  the  clavicle,  the  accident  being  often  described 
as  dislocation  of  the  acromial  end  of  the  collar  bone. 

Frequency  of  Occurrence. — In  the  St.  Thomas's  series  of  1207  dislocations,  dis- 
placement of  the  acromion  occurred  32  times,  or  2.65  per  cent.  In  Kronlein'  s  400,  it  oc- 
curred 11  times,  or  2.7  per  cent. 

Causation. — The  displacement  is  rare  except  in  adult  men,  and 
almost  invariably  results  from  the  exertion  of  direct  violence  on  the 
acromion,  either  by  falls  on  or  blows  received  by  the  upper  and  outer 
aspect  of  the  shoulder.  It  has  been  observed,  however,  as  a  result  of 
violence  applied  to  the  clavicle  from  below,  as  when  the  trunk  is  run 
over  by  a  wheel.  The  acromion  may  pass  in  one  of  two  directions, 
either  beneath  or  above  the  clavicle.  Of  these,  the  latter  is  extremely 
rare. 

Pathology. — The  degree  of  displacement  varies  greatly,  depending  on  the  extent  of 
injun-  to  the  coracoclavicular  ligaments.  If  these  are  but  slightly  damaged,  the  clavicle 
rides  just  beyond  its  normal  relation  to  the  cleft,  and  the  main  injury  is  to  the  acromiocla- 
vicular capsule.  When  the  conoid  and  trapezoid  ligaments  are  both  widely  injured,  the 
acromion  takes  up  a  much  more  internal  position.  Complete  rupture  of  both  conoid  and 
trapezoid  and  of  the  coraco-acromial  ligament  occurs  when  the  acromion  takes  up  a  position 
on  the  upper  surface  of  the  clavicle.  The  clavicle  then  rests  between  the  displaced  process 
and  the  upper  aspect  of  the  supraspinatus  and  shoulder-joint. 

Symptoms — Subclavicular  Dislocation. — The  shoulder  is  depressed 
and  approximated  to  the  median  line.  The  acromial  end  of  the  clavicle 
forms  a  localized  prominence,  marginating  internally  a  distal  depression. 
The  axis  of  the  clavicle  is  so  altered  as  to  increase  its  upward  and  out- 
ward slope,  and  the  supraclavicular  hollow  is  considerably  deepened 
as  a  result  of  the  tension  of  the  clavicular  insertion  of  the  trapezius. 


6l8  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

On  manipulation,  the  displacement  is  readily  reduced  by  raising  the 
shoulder  and  making  direct  pressure  on  the  clavicle.  The  individual 
features  vary  with  the  degree  of  the  displacement  of  the  acromion 
inward. 

Dislocation  Upward. — This  results  from  force  applied  to  the  clav- 
icle from  above,  and  is  very  rare.  Hamilton  has  pointed  out  that  the 
displacement  is  only  possible  when  the  lower  angle  of  the  scapula  is 
rotated  outward  and  the  coracoid  process  depressed,  the  clavicle  being 
thus  deprived  of  the  support  normally  offered  by  the  latter.  The 
function  of  the  upper  extremity  is  much  interfered  with.  On  inspec- 
tion the  shoulder  is  depressed,  the  arm  being  closely  approximated  to 
the  trunk  and  apparently  elongated.  The  distance  between  the  promi- 
nence of  the  shoulder  and  the  mid-line  is  shortened.  A  hollow  exists 
over  the  situation  of  the  dislocation  ;  the  axis  of  the  clavicle  sinks 
from  within  outward  ;  the  sternal  end  projects  abnormally.  The  cleido- 
mastoid  is  very  prominent.  On  manipulation,  although  voluntary 
movement  of  the  shoulder  is  practically  abrogated,  all  movements 
except  those  of  abduction,  and  to  a  less  extent  of  adduction,  can  be 
made  passively,  but  with  the  infliction  of  very  considerable  pain. 

Diagnosis. — These  injuries,  since  they  are  occasioned  by  direct 
violence,  are  apt  to  be  followed  by  rapid  and  much  greater  local 
swelling  than  dislocations  of  the  sternal  extremity  of  the  clavicle. 
The  only  likely  sources  of  confusion  are  fractures  in  the  immediate 
vicinity.  General  rules  of  differentiation  should  here  suffice,  bearing 
in  mind  that  in  fracture  the  cleft  is  narrower,  local  tenderness  more 
marked  and  circumscribed,  while  the  tendency  to  complete  recurrence 
of  the  deformity  is  greater  in  these  particular  dislocations  than  in 
fracture. 

Prognosis. — Entire  removal  of  the  deformity  is  rarely  attained. 
The  most  promising  cases  are  those  in  which  the  coracoclavicular  liga- 
ments have  suffered  little.  But  if  the  deformity  cannot  be  permanently 
reduced,  the  restoration  of  function  is  almost  complete,  free  abduction 
being  the  only  movement  endangered. 

Treatment. — The  first  indication  is  to  draw  the  shoulder  outward  ; 
and  this  position  must  be  maintained  by  the  arrangement  of  a  pad  in 
the  axilla.  The  arm  is  then  best  supported  and  the  scapula  kept 
at  rest  by  the  application  of  a  plaster-of-Paris  case  similar  to  that 
described  for  the  clavicular  dislocations.  The  elbow  must  be  well 
brought  forward,  and  direct  pressure  made  over  the  seat  of  the  articu- 
lation by  a  pad  or  moulded  plate  of  gutta-percha,  fixed  by  a  strip  of 
stout  strapping  carried  over  the  shoulder  and  around  the  flexed  fore- 
arm, just  below  the  point  of  the  olecranon.  When  deformity  is  marked 
and  reduction  especially  difficult  to  maintain  a  temporary  wire  suture 
may  be  inserted  with  advantage. 

Whatever  mode  of  fixation  is  employed,  it  is  necessary-  to  maintain  it  for  at  least  five  or 
six  weeks.  The  result  depends  mainly  on  the  degree  of  injury  to  the  ligaments  ;  but,  even 
if  deformity  persists,  the  functional  capacity  will  probably  be  good,  the  movement  most 
likely  to  be  restricted  being  that  of  free  abduction. 

The  lower  angle  of  the  scapula  occasionally  escapes  from  beneath  the  latissimus  dorsi. 
This  accident  is  most  common  as  the  result  of  paralysis  of  the  serratus  magnus  or  as  accom- 
panying scoliosis. 


SPECIAL   DISLOCATIONS.  6 1 9 

The  Humerus. — The  shoulder  surpasses  every  other  joint  in  the 
body  in  freedom  of  range  and  variety  of  movement.  These  character- 
istics necessitate  arrangements  ill  adapted  to  withstand  violence  from 
without,  which  arrangements,  although  modified  by  freedom  of  mobility 
and  possibilities  of  adaptation,  yet  render  the  joint  more  prone  to  dislo- 
cation than  any  other  in  the  body. 

The  peculiarities  which  render  it  specially  liable  to  displacement  may  be  shortly  summed 
up  as  follows  :  The  prominence  and  exposed  position  of  the  articulation  ;  the  length  of  the 
humerus,  and  its  consequent  power  as  a  lever  when  brought  to  bear  on  the  capsule  and  sur- 
rounding structures  ;  the  slackness  of  the  capsule,  and  the  want  of  direct  support  of  this 
structure  at  its  lower  and  inner  part ;  the  shallowness  and  comparatively  small  surface-area 
of  the  glenoid  cavity,  amounting  to  only  about  one-third  of  that  offered  by  the  humeral 
head  ;  and  the  fact  that  the  movement  of  abduction  of  the  humerus  is  normally  checked 
mainly  by  tension  of  the  capsular  ligament.  As  compensations  for  these  weak  points  we 
have  :  The  abundance  and  strength  of  the  tendinous  insertions  into  the  capsule,  which 
supply  a  complete  covering,  except  below  ;  the  special  arrangement  of  the  biceps  tendon, 
which  checks  displacement  upward  in  the  hanging  position,  downward  in  the  abducted 
state,  as  well  as  rotation  outward  in  extreme  supination  of  the  forearm  ;  the  mobility  of  the 
junction  of  the  clavicle  with  the  acromion,  which  allows  the  glenoid  cavity  to  be  brought 
directly  behind  the  head  of  the  humerus  when  the  arms  are  thrust  forward  ;  the  mobility  of 
the  scapula,  which  renders  it  difficult  for  the  humeral  lever  to  be  brought  suddenly  to  bear 
on  a  fixed  point ;  the  fact  that  forced  abduction  of  the  humerus — the  most  dangerous  move- 
ment— occurs  only  when  the  person  is  taken  unawares  ;  and  lastly,  the  protection  afforded 
to  the  shoulder  by  the  overhanging  shoulder-girdle. 

Frequency  of  Occurrence. — In  the  St.  Thomas's  series  of  1207  dislocations  539  of 
the  humerus  occurred,  forming  a  ratio  of  44.65  per  cent,  of  the  whole  number.  In  Kron- 
lein's  series  of  400,  207  occurred,  or  51.7  per  cent.  By  general  consensus  of  opinion,  at 
least  50  per  cent,  of  all  dislocations  take  place  at  the  shoulder-joint. 

Causation  and  Classification. — The  influence  of  age  and  the  male 
sex  is  strongly  marked  in  the  occurrence  of  dislocation  of  the  humerus. 
It  is  rare  before  the  age  of  twenty  ;  and  it  has  been  shown  by  Kronlein 
that  its  place  is  taken  in  early  childhood  by  fracture  of  the  then 
weak  clavicle,  while  later  the  still  unstable  elbow-joint  is  more  likely 
to  suffer.  After  twenty  the  proportion  continues  to  rise  steadily  until 
old  age. 

The  humerus  may  be  displaced  in  four  directions — forward,  back- 
ward, downward,  or  upward.  Of  these,  the  first  is  by  far  the  most 
common.  The  displacement  in  either  direction  may  vary  in  degree, 
but  the  following  classification  covers  all  the  main  varieties : 

1.  Forward:  Subcoracoid ;  Subclavicular. 

2.  Backward  :  Subacromial ;  Subspinous. 

3.  Downward  :  Subglenoid. 

4.  Upward  :  Supracoracoid. 

Two  of  the  rarer  varieties,  named  from  the  relative  position  of  the  arm  to  the  trunk, 
may  be  mentioned  :  Thus,  in  some  cases  of  subglenoid  dislocation,  the  arm  is  thrown 
upward  more  or  less  directly  in  the  reverse  of  the  normal  (hixatio  erectd),  and  in  some 
cases  of  subclavicular  dislocation  the  arm  has  been  noted  to  be  abducted  to  a  right  angle 
with  the  trunk  (hixatio  horizontalis,  Bardenheuer). 

Although  the  prominent  position  of  the  shoulder  frequently  exposes 
it  to  direct  injury,  dislocation  is  far  more  common  as  the  result  of 
indirect  violence.  Forcible  abduction  of  the  limb  is  the  most  frequent 
cause;  hence  the  majority  of  dislocations  are  primarily  subglenoid,  the 
humerus  obtaining  an  abnormal  fulcrum,  either  in  the  acromion  or  in 
the  impact  of  the  great  tuberosity  with  the  upper  part  of  the  glenoid 
cavity,  and  bursting  the  lower  part  of  the  capsule.  The  head,  as  the 
result  of  the  contraction  of  the   adductor  muscles  and  the  weight  of 


620  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

the  falling  limb,  travels  secondarily  into  one  of  the  anterior  positions, 
most  frequently  the  subcoracoid.  When  the  position  of  the  arm  is  the 
rare  one  of  combined  adduction,  flexion,  and  internal  rotation,  a  pos- 
terior dislocation  may  result;  but  the  nature  of  the  violence  is  nearer 
akin  to  the  direct,  as  the  rent  of  the  capsule  is  at  the  posterior  aspect. 
Direct  violence  may  be  applied  either  to  the  head  of  the  humerus  or 
to  its  lower  extremity.  When  applied  to  the  head  by  a  fall  or  a  blow, 
if  the  shoulder  is  struck  from  above  and  behind,  the  arm  being  rotated 
outward,  the  head  impinges  on  the  lower  and  anterior  portion  of  the 
capsule,  and  one  of  the  anterior  displacements  results.  When,  on  the 
other  hand,  the  force  is  applied  from  the  front  with  the  humerus  rotated 
inward,  the  upper  and  back  part  of  the  capsule  gives  way,  and  a  sub- 
spinous dislocation  is  developed.  A  fall  on  the  upper  aspect  of  the 
shoulder  may  also  fracture  the  acromion  process,  and  the  violence  being 
continued,  a  subglenoid  dislocation  may  follow.  In  falls  upon  the 
elbow,  the  mechanism  is  the  same,  forward  dislocation  depending  on 
an  extended  and  externally  .rotated  arm,  backward  dislocation,  on  a 
flexed  and  internally  rotated  one.  If. the  arm  is  rotated  outward  in 
the  degree  of  extension  assumed  by  the  limb  when  hanging  at  rest, 
the  rare  supracoracoid  form  may  result. 

As  to  the  relative  frequency  of  the  different  varieties,  of  the  539  dislocations  observed  at 
St.  Thomas's,  499  were  subcoracoid  or  subglenoid,  6  subclavicular,  and  6  subspinous.  No 
example  of  supracoracoid,  luxatio  erecta,  or  luxatio  horizontalis  is  recorded.  In  Kronlein's 
statistics,  of  207  dislocations,  203  were  subcoracoid  or  axillary,  3  luxationes  erecta-,  and  I 
subspinous.  In  the  St.  Thomas's  statistics,  the  subcoracoid  and  subglenoid  are  massed,  on 
account  of  the  different  opinions  as  to  the  discrimination  of  these  held  by  different  observers. 

Pathology. — In  the  subcoracoid  variety  the  head  of  the  humerus  lies  directly  beneath 
the  coracoid  process,  the  tip  of  the  latter  being  just  internal  to  the  bicipital  groove.  The 
great  tuberosity  rests  on  the  inner  and  under  part  of  the  glenoid  cavity,  the  anatomical 
neck  on  its  margin,  and  the  articular  portion  over  the  space  between  the  glenoid  cavity  and 
the  chest- wall.  The  short  head  of  the  biceps  and  the  coracobrachialis  cross  the  inner  part  of 
the  head,  while  the  remainder  projects  between  the  latissimus  dorsi  and  the  subscapularis. 
The  long  head  of  the  biceps  remains  in  its  groove,  and  crosses  the  glenoid  cavity  under  cover 
of  the  tense  supraspinatus  and  infraspinatus,  the  capsule  itself  being  pushed  back  by  the 
head  of  the  bone.  The  axillary  nerves  and  vessels  are  pushed  forward  and  inward  between 
the  subscapularis  and  pectoralis  major,  the  circumflex  nerve  lying  in  the  space  between  the 
subscapularis,  latissimus  dorsi,  and  humerus.      These  structures  are  seldom  injured. 

The  rent  in  the  capsule  is  either  transverse  or  oblique,  lies  at  the  lower  and  inner  aspect,  and 
involves  from  one-half  to  three-fourths  of  the  circumference  ;  but  it  has  been  found  so  small 
as  hardly  to  allow  the  passage  of  the  head,  while  in  very  rare  cases  it  has  been  entirely  sepa- 
rated from  its  humeral  attachment.  The  outer  and  upper  part  is  tensely  stretched  over  the 
glenoid  cavity.  The  lower  borders  of  the  subscapularis  and  teres  major  may  be  somewhat 
torn,  but  the'  former  is  usually  stretched  over  the  head  of  the  humerus.  The  deltoid,  the 
supraspinatus,  and  the  infraspinatus  are  tense.  The  last  two  sometimes  tear  off  a  part  of  the 
greater  tuberosity.  The  teres  minor  and  coracobrachialis  are  usually  uninjured.  The  long 
head  of  the  biceps  has  been  found  interposed  between  the  head  and  glenoid  cavity,  com- 
pletely displaced  outward  from  its  groove,  or  torn  through. 

Subclavicular. — A  slight  exaggeration  of  the  last  variety  was  named  intracoracoid  by 
Malgaigne,  and  considered  by  him  the  commonest  of  all  dislocations  of  the  humerus.  The 
head  may,  however,  pass  still  more  internally  and  rest  on  the  second  rib  and  serratus  magnus 
below  the  clavicle.  Such  dislocations  are  accompanied  by  the  more  severe  muscular  and 
ligamentous  injuries  enumerated  in  the  last  section,  especially  by  rupture  of  the  capsular 
muscles,  separation  of  the  great  tuberosity,  and  displacement  or  rupture  of  the  long  tendon 
of  the  biceps,  and  are  liable  to  compress  the  axillary  vessels  and  nerves. 

Subglenoid. — The  head  of  the  humerus  rests  on  the  upper  part  of  the  axillary  border  of 
the  scapula,  on  the  long  head  of  the  triceps,  which  is  sometimes  lacerated.  The  rent  in  the 
capsule  is  at  the  under  part.  The  deltoid  and  capsular  muscles  are  very  tense,  and  both  the 
greater  and  lesser  tuberosities  may  be  torn  off.  The  circumflex  nerve  is  sometimes  torn  or 
compressed;  the  axillary  artery  has  been  injured. 

Subspinous. — The  head  of  the  humerus  rests  on  the  posterior  margin  of  the  glenoid 


SPE  CIA  L    DISL  O  CA  Tl  OA  rS. 


621 


cavity,  or  beneath  the  acromion  process  at  its  junction  with  the  spine — very  rarely  beneath 
the  spine  proper.  The  head  is  covered  by  the  deltoid  alone,  or  sometimes  by  the  supra- 
spinatus  also.  The  subscapularis,  the  anterior  fibers  of  the  coracobrachialis,  and  the  short 
head  of  the  biceps  are  much  stretched  ;  the  long  tendon  of  the  biceps  follows  the  humerus. 
The  subscapularis  may  be  separated,  or  may  tear  off  the  lesser  tuberosity.  The  greater 
tuberosity  also  is  occasionally  torn  off  (Fig.  301). 


FlGS.  301,  302. — Subspinous  dislocation  of  the  humerus  (St.  Thomas's  Museum,  London). 

Symptoms. — Subcoracoid  Dislocation. — The  shoulder  is  depressed, 
the  arm  abducted  and  externally  rotated.  The  axis  of  the  humerus 
extends  from  above  downward,  backward,  and  outward.  The  infra- 
clavicular fossa  is  flattened,  the  anterior  wall  of  the  axilla  vertically- 
deepened,  and  a  prominence  corresponding  to  the  position  of  the  head 
of  the  humerus  occupies  its  outer  part.  The  axillary  folds  are  slack- 
ened and  the  cavity  shallowed.  The  shoulder  is  flattened  on  its  pos- 
terior and  outer  aspect,  while  the  acromion  projects  with  angular  outline. 
From  the  latter  the  deltoid  descends  vertically  and  meets  the  slanted 
humerus  at  an  angle.  The  forearm  is  usually  flexed,  pronated,  and 
supported  by  the  opposite  hand.  On  palpation  the  head  can  be  felt  in 
the  axilla,  as  the  arm  hangs  also  beneath  the  anterior  axillary  wall. 
The  acromion  is  readily  traced,  and  the  deltoid  beneath  is  in  a  state  of 
hollow  tension  over  the  empty  glenoid  cavity.  On  manipulation  the 
arm  is  rigid,  adduction  is  limited  and  only  to  be  made  by  the  employ- 
ment of  considerable  force,  and  both  adduction  and  flexion  are  very 
painful.  On  measurement  little  difference  is  to  be  made  out,  although 
the  head  of  the  humerus  is  at  least  ^  inch  lower  than  normal,  the  actual 
variation  being  obscured  by  the  obliquity  of  the  axis  of  the  shaft.  The 
axillary  circumference  is  increased  by  at  least  an  inch  (Fig.  303). 

As  already  observed,  the  head  may  take  up  a  more  internal  position 
and  still  be  in  close  relationship  to  the  coracoid  process.  Under  these 
circumstances  the  axis  of  the  humerus  is  more  oblique,  so  that  the 
abduction  is  apparently  less,  while  the  angle  formed  by  the  meeting  of 
the  deltoid  and  humerus  is  more  marked.  The  head  rests  more  deeply 
and  palpably  internal  to  the  coracoid  process  ;  hence  it  is  not  so  prom- 
inent anteriorly,  nor  can  it  be  felt  in  the  axilla  without  abducting  the 
arm.  There  is  internal  rotation.  Actual  crepitus  may  be  present,  due 
to  fracture  of  the  great  tuberosity,  and  the  limb  is  more  movable  as  a 


622 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


result  of  the  freer  laceration  of  the  capsule  and  other  soft  structures 
(Fig.  304). 


Fig.  303. — Subcoracoid  dislocation  of 
the  humerus  (St.  Thomas's  Museum,  Lon- 
don). 


Fig.  304. — Subcoracoid  dislocation  of  the 
humerus;  free  abduction  and  internal  rotation 
of  shaft  due  to  coexistent  fracture  of  the  greater 
tuberosity  (St.  Thomas's  Museum,  London). 


Subclavicular. — This  rare  dislocation  is  merely  an  increase  in  degree 
of  the  displacement  last  described.  The  head  of  the  humerus  travels 
so  far  inward  that  no  abduction  is  apparent ;  in  fact,  a  finger  can  with 
difficulty  be  inserted  into  the  axilla.  The  axillary  folds  are  much 
slackened ;  the  head  may  be  apparent  if  the  pectoralis  major  is  not 
highly  developed  or  is  torn,  and  can  be  felt  beneath  the  clavicle  inter- 
nal to  the  coracoid  process.  Free  mobility  and  possible  crepitus  are 
naturally  still  more  characteristic  of  this  variety  than  the  last.  In  rare 
cases  the  arm  has  assumed  a  position  of  abduction  at  a  right  angle. 

Subglenoid. — As  already  remarked,  this  is  the  initial  stage  of  most 
anterior  dislocations  due  to  indirect  violence,  especially  when  the 
abduction  is  continued  to  hyperelevation  (as  in  a  fall  through  a  manhole 
with  upstretched  arms),  under  which  circumstances  the  arm  sometimes 
retains  its  false  position,  the  axis  of  the  humerus  coursing  more  or  less 
directly  upward.  The  forearm  is  then  flexed,  the  hand  either  resting 
on  the  head  or  supported  by  the  sound  limb  (luxatio  crcctd).  The 
retention  of  the  subglenoid  position  appears  to  depend  on  opposite 
conditions  in  different  cases  :  in  some,  on  a  narrow  sht  in  the  capsule ; 
in  others,  on  very  free  laceration  of  the  capsule  and  muscular  insertions. 

In  typical  cases  the  shoulder  is  much  depressed  and  the  scapula 
advanced.  The  arm  is  very  strongly  abducted,  the  real  abduction  of  the 
humerus  being  greater  than  the  apparent,  since  it  is  lessened  by  the  rota- 
tion of  the  angle  of  the  scapula  toward  the  spine,  which  accompanies  the 
depression  of  the  shoulder.  The  anterior  wall  of  the  axilla  is  widened  ; 
there  is  no  prominence  below  the  coracoid  process,  and  the  hollow  of 
the  axilla  is  obliterated.     The  acromion  projects  strongly,  and  there  is 


SPECIAL   DISLOCATIONS.  623 

much  flattening  of  the  deltoid  area.  On  palpation,  the  head  of  the 
humerus  is  felt  in  the  axilla,  perhaps  a  little  nearer  to  the  anterior 
or  posterior  wall  respectively.  The  hollow  tension  of  the  deltoid  is 
extreme.  On  manipulation,  the  arm  may  be  swayed  a  little  forward 
or  backward,  but  adduction  is  strongly  opposed  and  extremely  painful. 
While  the  arm  remains  abducted  there  may  be  no  elongation ;  but 
when  adducted  in  the  process  of  reduction,  lengthening  may  amount 
to  as  much  as  an  inch.  The  axillary  vessels  and  nerves  are  often 
compressed. 

Subspinous. — As  in  the  anterior  dislocation,  the  degree  of  inward 
displacement  varies.  As  a  rule,  however,  the  head  of  the  humerus 
does  not  pass  further  inward  than  the  junction  of  the  spine  and  acro- 
mion process.  Deformity  is  often  not  so  marked  as  in  the  other  dis- 
locations, as  a  result  of  swelling  of  the  soft  parts  due  to  the  direct 
nature  of  the  violence  occasioning  the  displacement.  The  shoulder 
is  much  broadened  externally,  and  a  little  flattened  anteriorly.  The 
arm  is  slightly  flexed,  abducted,  and  rotated  inward ;  the  forearm  is 
pronated.  The  direction  of  the  axis  of  the  humerus  is  downward,  for- 
ward, and  outward.  On  palpation,  the  head  can  be  felt  beneath  the 
junction  of  the  spine  and  acromion,  especially  if  the  flexion  of  the  arm 
is  somewhat  increased.  There  is  hollow  tension  of  the  deltoid,  and 
occasionally  the  anterior  margin  of  the  glenoid  cavity  can  be  made  out. 
Both  the  acromion  and  coracoid  processes  are  more  readily  traced 
than  normal,  if  the  swelling  is  not  too  great.  All  movements  are  very 
painful,  especially  attempts  at  supination  of  the  forearm.  The  result 
of  measurements  is  very  variable. 

Iiifraspiuous. — In  the  very  rare  infraspinous  variety  the  broaden- 
ing of  the  shoulder  is  extreme.  As  in  the  subclavicular  variety,  the 
inward  position  of  the  head  brings  the  arm  against  the  trunk  and 
obscures  the  real  amount  of  abduction.  Flattening  between  the 
acromion  and  the  coracoid  process  is  more  marked,  and  the  infracla- 
vicular fossa  is  deepened  and  sometimes  crossed  by  the  tense  short 
head  of  the  biceps  and  coracobrachialis.  The  head  of  the  humerus  is 
readily  felt  below  the  scapular  spine. 

In  old  dislocations  the  abducted  position  is  less  marked,  having  undergone  gradual  cor- 
rection as  a  result  of  the  weight  of  the  dependent  arm.  On  the  other  hand,  the  disappear- 
ance of  swelling  and  the  atrophy  of  the  deltoid  give  marked  prominence  to  the  acromion  and 
coracoid  processes,  separated  by  a  vertical  groove  anteriorly,  and  to  the  head  on  the  dorsum 
of  the  scapula. 

Supracoracoid. — In  spite  of  its  rarity,  the  occurrence  of  this  dislo- 
cation has  been  fairly  established  ;  therefore  a  word  must  be  added  as 
to  its  signs. 

The  arm  is  adducted,  slightly  extended,  and  rotated  outward.  There 
is  no  flattening  of  the  deltoid,  and  the  head  forms  an  anterior  promi- 
nence between  the  acromion  and  coracoid  processes,  where  its  presence 
can  be  determined  by  palpation,  and  where  a  slight  hollow  beneath 
the  acromion  exists  behind  it,  in  which  the  posterior  margin  of  the 
glenoid  cavity  can  be  sometimes  felt.  The  coracoid  process  is  difficult 
to  distinguish,  and  may  be  fractured ;  in  this  case  crepitus  is  present. 

Diagnosis. — One  or  two  points  relating  to  the  investigation  of 
shoulder-dislocations  in  general  may  be  first  noticed.      1.  The  direc- 


624  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

tion  of  the  axis  of  the  humerus  is  the  cardinal  indication  of  the  posi- 
tion of  its  head;  and  it  may  be  further  noted  that  the  direction  of  the 
articular  surface  of  the  head  corresponds  with  that  of  the  internal  epi- 
condyle.  In  all  dislocations  of  the  humerus  except  the  rare  supra- 
coracoid,  the  shaft  of  the  bone  is  in  a  position  of  abduction,  even  if  this  be 
obscured  by  the  free  passage  of  the  head  on  to  the  anterior  or  posterior 
aspect  of  the  trunk.  2.  As  a  result  of  the  absence  of  the  prominence 
of  the  head  beneath  the  acromion,  a  straight  edge  applied  to  the  outer 
aspect  of  the  limb  will  rest  on  the  acromion  and  external  epicondyle. 
3.  The  axillary  circumference  is  increased  when  the  measure  is  carried 
around  at  the  level  of  the  junction  of  the  spine  and  acromion.  4.  The 
position  of  abduction  of  the  humerus  vitiates  any  measurements  carried 
from  the  acromion  to  the  external  epicondyle ;  hence,  these  are  of 
little  diagnostic  aid. 

The  discrimination  of  the  different  varieties  depends  on  careful 
investigation  for  the  signs  just  enumerated. 

The  differential  diagnosis  in  cases  of  severe  contusion  is  to  be  made  by  the  exclusion  of 
signs  of  displacement,  and  always  with  the  aid  of  an  anesthetic  when  any  doubt  exists. 
Contusion  accompanied  by  paresis  of  the  deltoid  may  slightly  simulate  a  dislocation  when 
the  primary  swelling  has  disappeared.  Here,  however,  no  sign  of  dislocation  except 
advancement  of  the  head  exists,  and  this  can  be  generally  corrected  by  lifting  the  elbow. 

Certain  fractures  may  give  rise  to  difficulty.  It  must  be  first  borne  in  mind  that  fracture 
of  a  tuberosity  may  accompany  a  dislocation.  If  this  be  the  case,  the  variations  of  the  typical 
signs  of  dislocation  will  be  the  addition  of  crepitus,  possibly  marked  local  tenderness,  a  ten- 
dency to  recurrence,  and  abnormal  rotation  of  the  long  axis  of  the  shaft.  Fracture  of  the 
neck  of  the  scapula,  of  the  neck  of  the  humerus,  or  separation  of  the  upper  humeral  epi- 
physis may  be  excluded  by  remembering  that  in  all  dislocations  the  head  leaves  its  position 
beneath  the  acromion,  and  that  the  axis  of  the  humerus  is  one  of  abduction.  In  all  three 
fractures,  the  head  is  in  position,  the  arm  is  adducted,  and,  in  addition,  the  deformity  exist- 
ing is  usually  reduced  with  ease,  and  returns  on  releasing  the  limb.  An  impacted  fracture 
of  the  neck  may  offer  more  trouble  ;  but  here  the  anterior  swelling  is  lower,  and  no  hollow 
exists  beneath  the  acromion. 

Care  is  sometimes  necessary  also  in  young  children  not  to  confuse 
a  forward-hanging  head  in  cases  of  infantile  paralysis  with  palsy,  or  a 
congenital  dislocation  with  a  recent  injury.  In  either  condition  the 
mobility  of  the  small  malplaced  head,  readily  returning  to  its  false 
position  when  released,  together  with  the  state  of  the  muscular  devel- 
opment of  the  limb,  will  be  sufficient  to  ensure  against  a  mistake. 

Prognosis. — As  to  immediate  reduction,  these  dislocations  seldom 
prove  intractable  ;  but  some  difficulty  is  often  experienced.  The  sub- 
clavicular variety  is  the  most  troublesome,  sometimes  proving  irreduci- 
ble, and,  as  a  result  of  the  extensive  injury  to  the  soft  parts,  often  being 
difficult  to  retain  in  position.  The  latter  difficulty  most  commonly 
depends  on  great  laceration  of  the  capsule ;  and  it  is  met  with  also  in 
the  subspinous  and,  occasionally,  other  forms.  In  all  varieties  a 
tendency  to  ready  recurrence  on  slight  injury  or  incautious  movement 
is  sometimes  observed. 

The  prognosis  may  be  materially  influenced  by  concurrent  injuries.  Of  these,  contiguous 
fracture,  as  of  the  tuberosities,  will  give  rise  to  difficulty  in  reduction  and  in  retaining  the 
joint-ends  in  accurate  position,  and  later  the  movement  of  the  joint  may  be  limited  either 
as  a  result  of  inexact  union,  the  presence  of  abundant  callus,  or  non-union  on  the  part  of 
the  fragments.  Again,  a  fracture  in  the  vicinity  may  offer  serious  obstacles  to  reduction. 
Injury  to  the  axillary  vessels  or  their  branches  may  also  be  a  serious  complication,  but  for- 
tunately it  is  rare.  Of  the  nerves,  the  circumflex  most  frequently  suffers,  and  the  resulting 
deltoid  paralysis  is  a  most  untoward  event. 


SPECIAL   DISLOCATIONS.  625 

When  unreduced,  subsequent  changes  already  dwelt  upon  occur 
in  the  joint,  and  in  the  absence  of  pressure-symptoms  a  fairly  use- 
ful limb  may  be  attained.  The  weight  of  the  limb  brings  the  arm 
to  the  side,  and  gradual  increase  of  range  of  movement  is  obtained 
by  exercise.  The  subclavicular  and  the  supracoracoid  are  the  most 
marked  exceptions  to  this  ;  while,  as  a  general  rule,  a  more  useful  limb 
is  obtained  in  the  case  of  the  anterior  than  the  posterior  displacement, 
since  a  better  new  joint-cavity  is  developed.  In  the  subspinous  dislo- 
cations the  head  rests  less  directly  on  the  bone,  and  the  spine  of  the 
scapula  does  not  offer  such  satisfactory  support'  above  as  does  the 
coracoid  process.  In  other  cases  the  persistence  of  the  displacement 
is  accompanied  by  great  pain  from  nerve-pressure,  especially  in  the 
subclavicular  variety,  and  is  followed  by  gradual  wasting  of  the  muscles 
and  fixation  of  the  joint. 

Attempts  at  reduction  are  justifiable  in  suitable  cases  as  late  as  the 
end  of  twelve  months,  but,  as  a  rule,  six  to  eight  weeks  may  be  given 
as  the  limit  of  the  period  in  which  they  are  likely  to  be  successful. 

Treatment. — If  the  patient  comes  under  immediate  observation,  an 
anesthetic  may  often  be  dispensed  wTith  as  unnecessary ;  in  other  cases 
it  may  be  inadvisable  on  general  grounds,  the  more  so  as  anesthesia 
needs  to  be  deep  to  be  useful.  If  the  dislocation  has  already  existed 
some  hours,  or  if  the  patient  is  nervous  or  of  strong  muscular  devel- 
opment, anesthesia  is  advantageous,  and  often  necessary. 

A  very  large  number  of  methods  of  reduction  have  been  employed, 
and  of  these  a  few  of  the  most  apparent  general  utility  will  be  given. 
It  may  be  premised  that  in  all  methods  one  of  the  most  important  ele- 
ments is  the  fixation  of  the  scapula.  The  scapula  may  be  fixed — first, 
by  pressure  on  the  part  of  an  assistant  over  the  acromion  process  and 
clavicle,  the  patient  being  either  in  the  sitting  or  recumbent  position  ; 
secondly,  by  applying  a  sheet  carried  well  up  to  the  axilla,  the  two 
ends  being  held  by  an  assistant  standing  on  the  opposite  side  of  the 
body  ;  thirdly,  by  dragging  on  the  opposite  arm,  which,  by  making  tense 
the  trapezius  of  the  opposite  side,  provokes  contraction  of  the  muscle  on 
the  injured  side;  and  lastly,  but  less  efficiently,  by  simply  placing  the 
patient  in  the  recumbent  supine  position.  In  all  the  methods  of  reduc- 
tion, use  is  made  of  the  humerus  as  a  lever.  This  bone,  by  reason  of 
its  length  and  strength,  is  capable  of  exerting  great  power;  and  in  this 
respect  it  is  well  to  bear  in  mind  that  in  some  of  the  so-called  manipu- 
lative methods,  the  leverage  exerted  is  so  great"  as  to  effect,  if  injudi- 
ciously used,  more  serious  local  injury  than  those  methods  of  exten- 
sion that  are  generally  regarded  as  more  violent  in  their  nature. 

Methods. —  1.  Abduction  of  the  arm  with  direct  digital  pressure  on 
the  head  from  the  axilla,  combined,  if  necessary,  with  moderate  traction 
and  rotatory  movements.  Rotation  should  first  be  made  in  an  external 
direction,  and  be  followed  by  internal  rotation  and  adduction.  This 
method  is  well  adapted  for  the  reduction  of  subcoracoid  dislocations  in 
weakly  developed  persons  and  in  the  young. 

2.  The  same  procedure,  but  with  increase  of  the  movement  of  abduc- 
tion  to   hyperelevation,   the   scapula   being   fixed.     This   is   especially 
suitable   to   some   cases   of  subglenoid   dislocation,   particularly  those 
with  slight  abduction  of  the  arm. 
"40 


620 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


3.  Manipulation  by  KocJicrs  Method. — The  patient  is  best  recum- 
bent, but  the  maneuvers   can   be  carried   out  in   the   sitting    position. 

First  Stage. — An  assistant  stands  behind  and  fixes  the  scapula  by 
pressure  on  one  or,  better,  both  acromion  processes.  The  surgeon 
grasps  the  patient's  forearm  above  the  wrist  with  one  hand,  and  the  arm 


FlG.  305. — Position  preparatory  to  making  traction  and  direct  pressure. 

at  the  elbow  with  the  other ;  the  abducted  limb  is  then  carried  against 
the  trunk  and  pressed  firmly  down.  This  corrects  the  direction  of  the 
axis  of  the  humerus  and  puts  the  upper  and  outer  part  of  the  capsule 
on  the  stretch  (Fig.  306). 

I 


FlG.  306. — Correction  of  abduction. 

Second  Stage. — The  arm  being  held  firmly  to  the  trunk,  the  forearm 
is  carried  by  external  rotation  of  the  humerus  nearly  into  the  frontal 
plane  of  the  trunk.  This  utilizes  the  tension  of  the  intact  part  of  the 
capsule  in  bringing  the  head  outward,  and  causes  the  rent  to  gape ;  it 
also  disengages  the  groove  on  the  anatomical  neck  from  its  position  on 
the  margin  of  the  glenoid  cavity  (Fig.  307). 


SPECIAL   DISL  OCA  TIONS. 


627 


Third  Stage. — The  arm  is  carried  across  the  body  in  the  frontal 
plane  and  internally  rotated.  This  brings  the  cartilage-clad  portion  of 
the  head  opposite  the  gap  in  the  capsule ;  and  the  head  should  now 
enter  the  glenoid  cavity  (Fig.  308).  It  will  be  observed  that  the  stage 
in  which  the  greatest  care  is  necessary  not  to  employ  excessive  force  is 
that  in  which  external  rotation  is  made.  The  method  is  applicable  to 
all  anterior  dislocations  ;  but  in  the  case  of  the  subclavicular  it  must 


Fig.  307. — Adduction  and  external  rotation. 

be  preceded  by  traction  to  draw  the   head  outward,  practically  into  a 
subcoracoid  position. 

4.  Manual  Extension  with  the  Heel  in  the  Axilla. — The  patient 
reclines,  while  the  scapula  is  fixed  by  a  towel  passed  over  the  acromion 
and  held  by  an  assistant  on  the  other  side.  The  surgeon  seats  himself 
on  the  edge  of  the  couch,  places  the  unshod  foot  in  the  axilla  of  the 
patient,  and,  grasping  the  forearm  just  above  the  wrist,  makes  steady 
traction,  at  first  in  the  axis  of  the  displaced  bone,  gradually  bringing 
the  limb  around  the  fulcrum  offered  by  the  heel  inward.  This  opens 
the  slit  in  the  capsule  at  the  same  time  that  the  head  is  carried  outward  ; 


FIG.  308. — Adduction,  flexion,  and  internal  rotation. 

and  the  head  is  usually  drawn  by  the  muscles  into  position.  A  move- 
ment of  rotation  at  the  termination  of  the  maneuver  may  be  useful. 
This  method  can  be  carried  out  without  assistance,  and  is  very  gener- 
ally useful.     At  the  same  time  it  must  be  borne  in  mind  that  the  heel 


628  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

in  the  axilla  has  been  responsible  for  many  of  the  complications  seen  in 
the  reduction  of  shoulder-dislocations,  particularly  injuries  to  the  vessels. 
5.  Extension  with  the  Knee  in  the  Axilla. —  The  patient  sits,  the  sur- 
geon standing  behind  him  and  placing  his  foot  on  the  stool.  Traction 
is  then  made  by  an  assistant,  the  surgeon  manipulating  the  head  with 
one  hand,  while  direct  downward  pressure  is  made  on  the  acromion 
with  the  other. 

6.  Hyperextension. — This  is  not  a  good  method  for  general  application,  as  it  is  liable  to 
cause  considerable  laceration  of  the  soft  structures.  It  may  be  applied  by  placing  the  patient 
in  the  recumbent  position.  The  surgeon  stands  at  the  head  of  the  couch,  and  grasps  the 
limb  with  both  hands;  then,  placing  the  hollow  of  the  foot  on  the  acromion  process,  he 
makes  extension,  which  is  carried  to  a  needful  degree  of  hyperelevation.  Another  method 
is  the  so-called  "pendulum  method"  in  which  the  patient  lies  on  the  floor  on  the  uninjured 
side.  The  injured  arm  is  then  grasped  and  traction  made,  the  weight  of  the  body  serving 
as  counterextension. 

Any  of  these  purely  manual  methods  may  be  combined  with  traction  by  pulleys  ;  or  in 
very  obstinate  or  old  cases  the  whole  method  may  be  varied,  pulleys  being  employed  for  pur- 
poses of  extension,  while  counterextension  is  obtained  by  one  towel  carried  around  the  axilla 
and  another  around  the  body  to  fix  the  scapula.  The  directions  given  as  to  ancillary  move- 
ments of  manipulation,  of  course,  apply  equally  here. 

Posterior  displacements  are  best  treated  by  one  of  the  extension  methods. 

After  reduction,  a  small  pad  should  be  placed  in  the  axilla,  the  fore- 
arm flexed,  and  the  arm  firmly  bandaged  to  the  side.  At  the  end  of  a 
week  a  sling  maybe  substituted  for  the  bandage,  and  slight  movements 
cautiously  made.  These  may  be  increased  during  the  next  few  weeks, 
and  combined  with  warm  bathing  and  massage.  It  must  always  be 
remembered  that,  on  the  one  hand,  these  dislocations  are  liable  to  be 
readily  followed  by  stiffness  and  atrophy  of  muscles,  if  not  treated 
with  sufficient  care  as  to  movement ;  while,  on  the  other  hand,  too  free 
movements  tend  to  the  development  of  a  widened  capsule — so  often  a 
source  of  permanent  weakness  and  tendency  to  recurrence.  Imme- 
diate recurrence  or  recurrence  during  the  first  days  is  rare.  It  depends 
either  on  careless  movements  of  the  patient,  the  limb  being  insecurely 
fixed,  on  great  laceration  of  the  tissues,  detachment  of  the  tuberosities, 
or  possibly  on  the  collection  of  a  large  amount  of  synovial  and  san- 
guineous effusion. 

In  a  small  proportion  of  cases  a  dislocation  is  followed  by  the 
acquisition  of  so  marked  a  tendency  to  recurrence  that  displacement 
becomes  habitual  on  the  slightest  uncontrolled  movement  of  abduction. 
For  this  condition  the  treatment  is  massage  and  exercise,  or  strict  limita- 
tion of  movement  by  the  constant  use  of  suitable  braces,  or  an  incision 
with  shortening  of  the  capsule  by  excision  of  the  stretched  portion. 

Compound  and  Complicated  Dislocations.  —  The  former  are 
extremely  rare.  As  a  rule,  they  demand  conservative  treatment 
only ;  but  a  limited  excision  may  be  useful  to  facilitate  reduction 
and  ensure  future  drainage. 

The  question  of  complication  by  fracture  of  the  shaft  of  the  bone  has  been  already 
alluded.  Mention  should  be  made  of  McBurney's  method  of  exposing  the  lower  end  of 
the  upper  fragment  and  inserting  a  hook  into  it,  by  which  traction  was  made  and  the  disloca- 
tion successfully  reduced. 

If  the  axillary  artery  or  vein  lias  be<  injured  and  a  diffuse  trau- 
matic aneurysm  has  developed,  the  onh  treatment  is  free  opening  up 
of  the  axilla  by  division  of  the  pectoral  muscles,  rapid  clearance  of  the 


SPECIAL   DISLOCATIONS.  629 

clot,  and  search  for  the  bleeding  point,  the  third  part  of  the  subclavian 
being  meanwhile  compressed.  The  success  of  this  formidable  opera- 
tion depends  entirely  on  freedom  of  incision  and  rapidity  of  procedure. 
When  the  axilla  is  opened  up,  direct  pressure  on  the  axillary  vessels 
may  take  the  place  of  the  less  efficient  proximal  compression  of  the 
subclavian. 

Old  Dislocations. — -The  same  methods  of  reduction  are  available ; 
but  we  must  bear  in  mind  the  changes  which  have  occurred,  such  as 
the  formation  of  adhesions,  particularly  of  the  capsule  to  the  glenoid 
cavity,  the  shortening  of  some  parts  of  the  capsule  and  surrounding 
structures  and  the  corresponding  lengthening  of  others,  and  even  the 
thickening  and  loss  of  contour  of  the  bone-surfaces.  Any  method  of 
reduction  must  be  preceded  by  free  passive  movements  in  all  directions, 
to  break  down  adventitious  adhesions.  Kocher's  manipulations  may 
then  be  tried,  followed  by  extension  methods  if  necessary ;  but  the 
external  rotation  in  Kocher's  method  must  be  cautiously  employed,  to 
avoid  fracture  of  the  humerus  from  torsion,  which  has  several  times 
occurred.  Efforts  have  been  successful  up  to  nine  and  even  twenty-one 
months,  but,  as  a  general  rule,  six  months  is  the  latest  hopeful  limit. 

In  deciding  on  a  trial,  several  points  must  be  fully  considered ;  and 
these  are  not  the  less  to  be  kept  in  mind  in  the  carrying  out  of  the 
necessary  manipulations,  some  cases  naturally  allowing  of  a  much  more 
forcible  treatment  than  others.  These  points  may  be  grouped  shortly 
as  follows:  1.  The  degree  of  usefulness  of  the  limb;  2.  The  age  and 
occupation  of  the  patient ;  3.  The  condition  of  the  blood-vessels  ;  4. 
The  existence  of  evidence  of  nerve-pressure  ;  5.  The  degree  of  previous 
inflammation  which  may  have  existed;  6.  Whether  the  original  injury 
was  complicated  by  fracture. 

Loss  of  function  and  pain  are  the  most  pressing  indications  for 
interference,  and  under  these  circumstances  any  of  the  above  methods 
may  be  inadequate,  and  an  operative  method  may  be  demanded.  Sub- 
cutaneous incision  may  be  passed  over  with  a  word,  as  seldom  likely  to 
be  of  definite  use  ;  but,  occasionally,  persistent  deformity  and  pressure- 
symptoms  may  be  relieved  by  altering  the  axis  of  the  limb  by  means 
of  subcutaneous  osteotomy.  Open  incision  and  reposition  are  suitable 
to  some  cases  in  which  the  dislocation  is  of  short  standing ;  and  it  may 
be  combined  with  pegging  or  suture  of  the  great  tuberosity,  if  this  is 
loose  and  leads  to  difficulty  in  keeping  the  bones  in  apposition.  Excision 
of  the  joint  has  proved  very  successful  in  cases  in  which  nerve-pressure 
and  deficiency  in  movement  are  prominent  features.  No  more  than  the 
articular  portion  of  the  head  needs  removal  in  the  majority  of  instances. 
In  deciding  to  adopt  this  treatment,  the  temperament  of  the  patient 
needs  especially  careful  consideration,  since  no  good  result  will  be 
obtained  unless  sufficient  capacity  exists  for  the  endurance  of  a  con- 
siderable amount  of  suffering  in  the  after-treatment  by  passive  exercise. 

Lastly  must  be  enumerated  the  accidents  which  have  happened 
during  trials  at  reduction  of  dislocations  of  the  shoulder.  They  are 
placed  here  because  it  is  in  old  dislocations  that  the  majority  of  them 
have  occurred.  These  are  shortly  :  1.  Severe  contusion  of  the  soft 
parts,  perhaps  followed  by  cellulitis  ;  2.  Great  subcutaneous  laceration 
of  the  capsule  and  muscles ;    3.  Laceration  of  the  blood-vessels,  espe- 


630  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

cially  the  tearing  of  one  of  the  lateral  branches  of  the  axillary  artery 
by  the  heel  in  the  axilla  ;  4.  Injury  to  the  nerves  of  the  brachial  plexus; 
5.   Fracture  of  the  humerus,  or  ribs;    6.  Avulsion  of  the  limb. 

Radius  and  Ulna. — The  elbow-joint  offers  the  most  complicated 
bony  surfaces  for  contact  of  any  articulation  in  the  body,  while  bony 
apophyses,  projecting  on  either  side,  give  increased  power  and  range 
of  action  to  the  muscles  which  act  upon  it. 

Its  stability  depends  on  the  depth  of  the  sigmoid  cavity  of  the  ulna,  the  more  important 
of  the  two  bones  of  the  forearm  taking  part  in  the  articulation  ;  it  depends  also  upon 
the  great  strength  of  its  lateral  ligaments,  and  the  support  given  by  the  triceps  behind,  the 
brachialis  anticus  in  front,  and  the  flexor  and  extensor  muscles  of  the  forearm  on  either 
side.  The  special  characteristics  of  dislocations  of  the  elbow-joint  depend  on  the  num- 
ber of  separate  prominences  offered  by  the  bones,  and  on  the  fact  that  the  movements  of 
the  joint  are  for  the  most  part  limited  by  actual  bony  contact  of  some  one  of  these  processes 
on  the  corresponding  cavity  of  reception.  The  presence  of  a  number  of  bony  prominences 
accounts  for  the  frequency  with  which  these  dislocations  are  accompanied  by  fracture,  while 
the  processes  often  form  the  abnormal  fulcrum  by  which  the  bones  are  levered  out  from 
their  proper  relationship. 

Frequency  of  Occurrence. — In  the  St.  Thomas's  series  of  1207  dislocations,  222  of 
the  elbow  occurred,  forming  a  ratio  of  18.39  per  cent,  of  the  whole  number.  In  Kronlein's 
series  of  400,  109  occurred,  or  27.2  per  cent.  The  dislocation  therefore  stands  second  in 
order  of  relative  frequency. 

Causation  and  Classification. — In  no  other  joint  is  the  influence  of  sex  and  age  so 
intimately  connected  with  the  concurrence  of  dislocation  as  in  the  elbow.  Thus,  in  our 
table  of  222  dislocations,  186  were  in  males,  and  only  36  in  females  ;  in  6  the  age  was 
unstated,  but  of  the  remainder,  54  occurred  between  the  ages  of  five  and  ten,  112  between 
the  ages  of  ten  and  twenty,  leaving  only  50  to  be  distributed  in  steadily  increasing  infre- 
quency  over  the  remaining  decades. 

In  children  the  shallowness  of  the  cavities  of  reception  and  the  corresponding  want  of 
prominence  of  the  processes  allow  dislocation  to  occur  more  readily  (Bardenheuer).  Again, 
the  mode  of  development  of  the  lower  humeral  epiphysis  predisposes  to  dislocation  by  offer- 
ing special  opportunities  for  epiphyseal  separation,  the  centers  of  ossification  being  multiple. 
Considering  the  frequency  with  which  separation  of  one  of  the  condyles  occurs  with  disloca- 
tion, this  is  a  point  of  much  importance.  It  must,  however,  be  borne  in  mind  that  separa- 
tion of  the  lower  epiphysis,  as  a  whole,  often  saves  the  elbow-joint  from  injury. 

The  great  majority  of  the  dislocations  are  due  to  indirect  violence, 
and  result  from  falls  on  the  extended  pronated  hand  spread  out  to  save 
the  trunk  from  sudden  impact  with  the  ground.  With  a  fully  extended 
forearm  the  elbow-joint  usually  escapes  injury ;  but  if  a  slight  degree 
of  flexion  exists,  dislocation  often  occurs,  and  most  frequently  in  a 
backward  direction.  The  latter  may  be  further  influenced  by  abduc- 
tion and  rotation  of  the  arm  due  to  the  continuing  movement  of  the 
trunk  either  forward  or  backward  as  it  travels  to  the  ground,  while 
the  hand  remains  a  fixed  point.  More  rarely,  violent  abduction  or 
adduction  gives  rise  to  rupture  of  the  external  or  internal  lateral  liga- 
ments, or  to  separation  of  the  corresponding  epicondyles,  with  conse- 
quent displacement  of  the  bones  of  the  forearm  in  the  opposite  direc- 
tion to  the  lateral  rupture.  Again,  dislocation  may  result  from  hyper- 
extension  or  forcible  rotation,  the  latter  especially  in  machinery  acci- 
dents. Direct  violence  applied  to  the  olecranon  process  or  to  the 
inner  side  of  the  flexed  forearm  may  give  rise  to  displacement  forward 
or  outward  respectively. 

The  bones  of  the  forearm  may  pass  in  either  of  the  four  angular 
directions — backward,  forward,  outward,  or  inward.  Of  these,  back- 
ward is  by  far  the  most  common.  The  rarity  of  the  inward  displace- 
ments is  readily  explained  by  the  great  prominence  of  the  inner  edge 
of  the  trochlear  groove  and  the  projection   of  the  inner  epicondyle. 


SPECIAL   DISLOCATIONS.  631 

Except  in  the  case  of  the  backward  variety,  complete  dislocation  of  the 
bones  is  rare.  Of  our  222  cases,  the  direction  is  reported  as  follows: 
Backward,  109  ;  back  and  out,  52  ;  outward,  18  ;  back  and  in,  6;  diver- 
gent, 6 ;  forward,  I  ;  double  1 . 

Pathology. — -The  injury  to  the  bones  and  soft  parts  is  briefly  as  follows  in  the  different 
varieties  : 

Backward  Dislocation. — The  coronoid  process  rests  in  the  olecranon  fossa,  the  radial 
head  behind  the  capitellnm.  The  internal  epicondyle  may  be  separated,  or  more  rarely  the 
coronoid  process  fractured.  The  anterior  part  of  the  capsule  is  completely  torn,  also  the 
anterior  parts  of  the  lateral  ligaments,  especially  the  inner.  The  orbicular  ligament  is 
unhurt,  and  the  posterior  part  of  the  capsule  often  escapes  injury  also,  while  the  anterior  torn 
portion  may  be  interposed  between  the  displaced  bones.  Of  the  muscles,  the  brachialis  anti- 
cus  suffers  most.  This  is  tense,  and  often  is  severely  lacerated.  The  biceps  is  less  tense." 
The  brachial  artery  is  compressed.  The  median  and  musculospiral  nerves  are  stretched. 
The  ulnar  usually  escapes  injury,  probably  as  the  result  of  lateral  displacement.  The  skin 
of  the  crease  of  the  elbow  sometimes  gives  way  when  the  accident  results  from  forcible 
hyperextension.  The  displacement  is  occasionally  less  complete,  when  the  coronoid  process 
rests  against  the  trochlea  instead  of  occupying  the  olecranon  fossa. 

Fortvard  Dislocation. — The  end  of  the  olecranon  rests  on  the  front  of  the  trochlea,  and, 
contrary  to  the  opinion  at  one  time  held,  is  rarely  fractured  and  left  behind.  The  rent  in 
the  capsule  is  very  extensive,  both  anterior  and  posterior  aspects  being  much  torn.  The 
internal  lateral  ligament  is  much  damaged,  the  external  less  so.  Fracture  of  one  of  the 
processes  of  the  ulna  or  one  of  the  epicondyles  is  common. 

Lateral  Dislocations. — The  injury  in  these  cases  resembles  that  described  for  the  other 
varieties,  with  the  difference  that  the  corresponding  lateral  ligament  suffers  more  completely. 
In  the  outer  variety  there  is  often  much  injury  to  bony  processes,  and  the  ulnar  nerve,  or  less 
often  the  posterior  interosseous  nerve,  is  stretched  or  torn.  The  sigmoid  cavity  rarely  passes 
beyond  the  capitellum. 

Divergent  Dislocation. — In  this  variety  the  articular  end  of  the  ulna  passes  backward, 
and  usually  is  a  little  rotated  inward.  The  head  of  the  radius  lies  in  front  of  the  humerus 
also,  somewhat  internal  to  its  proper  position,  as  well  as  too  high.  The  main  feature  in  the 
injury  to  the  soft  parts  is  the  complete  rupture  of  all  the  ligaments,  including  even  the  orbicu- 
lar. In  Pitha's  case  the  coronoid  process  was  separated,  and  the  brachialis  and  biceps  were 
torn  from  their  insertions. 

The  frequency  of  co-existing  fracture  has  no  doubt  been  much  underrated.  In  the  St. 
Thomas's  series  30  fractures  are  noted  thus:  Internal  condyle,  18;  external  condyle,  3; 
coronoid  process,  3;  olecranon,  I;  separation  of  lower  humeral  epiphvsis,  1  ;  fracture  of 
radius,  I  ;  fracture  of  ulna,  I  ;  fracture  of  both  radius  and  ulna,  2.  These  amount  to  30, 
or  18  per  cent,  of  the  whole  number;   but  in  all  probability  many  cases  were  overlooked. 

Symptoms. — In  backward  dislocation  the  elbow  is  slightly  flexed, 
usually  forming  an  angle  of  135  degrees.     The  flexion  is  accompanied 


Fig.  309. — Backward  and  outward  dislocation  from  behind  (St.  Thomas's  Museum,  London). 

by  some  abduction  in  the  majority  of  cases,  due  to  the  fact  that  the 
displacement  is  in  part  the  result  of  forced  abduction,  and  hence  not 
directly  backward.  Tension  of  the  pronator  teres  also  commonly  pro- 
duces some  pronation ;    but  the  forearm  may  be  supine.     The  long 


632  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

axes  of  the  arm  and  forearm  cross  each  other;  the  forearm  is  short- 
ened, while  the  diameter  of  the  arm  above  the  elbow  is  increased.  The 
elbow-crease  is  pushed  down  and  prominent,  the  olecranon  and  internal 
epicondyles  are  prominent,  and  the  tense  triceps  is  sometimes  visible 
stretching  up  from  the  former  process.  ( )n  palpation  the  olecranon  is 
prominent  and  projects  behind  and  above  the  internal  epicondyle.  The 
cup-shaped  radial  head  may  be  felt  posteriorly,  and  it  is  absent  from  its 
normal  position  beneath  the  external  epicondyle.  If  the  swelling  is 
not  great,  the  articular  surface  of  the  humerus  may  be  traced  in  the 
bulging  elbow-crease.  On  manipulation  all  movements  are  painful, 
and  are  made  in  an  abnormal  axis.  Pronation  and  supination  and 
flexion  to  a  right  angle  may  be  made;  but  practically  no  extension  is 
possible.     Abnormal  lateral  mobility  may  exist. 

Forward  Dislocation. — This  displacement  is  very  rare,  and  its  occur- 
rence without  coexisting  fracture  of  the  olecranon  has  been  doubted. 
In  point  of  fact,  however',  the  latter  complication  has  been  still  more 
rarely  recorded.  On  inspection  the  forearm  is  usually  found  flexed  to 
an  acute  angle,  but  it  has  been  seen  extended.  The  actual  length  of 
the  arm  is  decreased,  and  the  vertical  diameter  of  the  forearm  increased. 
The  epicondyles  are  prominent.  In  the  absence  of  the  olecranon,  the 
outline  of  the  posterior  surface  of  the  humerus  may  be  traced  on  pal- 
pation. Anteriorly,  the  coronoid  process,  and  even  the  sigmoid  cavity, 
may  be  felt.  On  manipulation,  the  forearm  may  be  somewhat  extended, 
but  the  amount  of  flexion  existing  cannot  be  increased. 

Outward  Dislocation. — The  forearm  is  slightly  flexed,  the  radius 
usually  strongly  pronated,  as  the  head  generally  fails  to  maintain  its 
outward  position  and  passes  forward.  In  the  exceptional  instances  in 
which  the  radius  projects  outward,  the  forearm  may  be  supine.  The 
whole  joint  is  broadened,  and  if  the  radius  is  much  rotated,  the  vertical 
diameter  of  the  forearm  is  increased  also.  When  the  limb  hangs  by 
the  side,  the  forearm  is  seen  to  be  markedly  abducted.  The  inter- 
nal epicondyle  is  very  prominent.  If,  as  is  commonly  the  case,  the 
outward  displacement  is  combined  with  a  backward  one,  the  olecranon 
and  the  triceps  tendon  are  prominent,  and  also  abnormally  widely 
separated  from  the  internal  epicondyle. 

On  palpation  the  signs  will  differ  with  the  degree  of  external  dis- 
placement and  as  to  whether  it  is  combined  with  a  backward  one.  In 
the  pure  outward  cases  the  sigmoid  cavity  usually  embraces  the  capi- 
tellum.  The  radial  head  is  then  to  be  felt  a  little  anterior  and  external 
to  the  outer  epicondyle,  while  internally  and  behind,  the  internal  epi- 
condyle and  olecranon  fossa  may  be  traced,  and  the  point  of  the  olec- 
ranon is  removed  from  its  normal  proximity  and  relation  to  the 
former.  The  biceps  tendon  is  displaced  inward,  and  is  tense  and 
prominent.  If  the  inner  condyle  should  have  been  separated,  it  may 
lie  in  either  the  olecranon  or  coronoid  fossa,  and  the  trochlea  will  take 
its  place  as  the  most  internal  landmark.  On  manipulation  rigidity  of 
the  flexed  joint  is  a  marked  feature.  There  may  be  symptoms  point- 
ing to  injury  to  the  ulnar  nerve,  which  is  particularly  exposed  to  press- 
ure, stretching,  or  laceration  in  a  displacement  of  this  variety. 

Dislocation  Inward. — The  elbow  is  slightly  flexed  and  markedly 
pronated.     As  the  limb  hangs  by  the  side,  adduction  is  sufficient  to 


SPECIAL   DISLOCATIONS.  633 

reverse  the  normal  angle  of  the  elbow,  the  angle  being  salient  outward, 
and  the  external  epicondyle  prominent.  On  palpation  the  olecranon 
rests  beneath  the  internal  epicondyle  and  obscures  it;  the  outer  epicon- 
dyle is  prominent,  and  the  capitellum  is  to  be  felt.  The  head  of  the  radius 
must  be  searched  for  anterior  to  the  trochlea.  The  distance  between  the 
olecranon  and  the  external  epicondyle  is  much  increased  ;  the  latter  may 
be  separated.  Complete  dislocation  of  the  bones  inward  does  not  occur, 
but  inward  displacement  may  be  combined  with  a  backward  one. 

Divergent  Dislocation  (Ulna  Backward;  Radius  Forward). — The 
forearm  is  slightly  flexed,  and  rests  midway  between  pronation  and 
supination.  The  elbow-crease  is  obliterated,  and  filled  by  a  promi- 
nence due  to  the  position  of  the  head  of  the  radius.  The  vertical 
diameter  of  the  forearm  is  increased,  the  lateral  not.  The  whole  limb 
is  shortened  ;  but  upon  measurement  the  individual  segments  are  found 
to  be  of  normal  length.  The  shortening  may  amount  to  from  1  to  3 
inches.  On  palpation  the  condyles  are  abnormally  prominent,  and 
parts  of  the  articular  end  of  the  humerus  may  be  felt  on  each  side. 
The  olecranon  is  above  its  normal  level,  but  often  approximated  to 
the  inner  condyle.  On  manipulation,  the  limb  is  very  rigid,  any  flexion 
particularly  being  opposed  by  the  head  of  the  radius.  Less  pronation 
and  supination  are  possible  than  in  any  other  variety. 

Diagnosis  of  Dislocations  of  the  Elbow. — A  determination  of  the 
particular    variety    of    dislocation    can    be    made    only    by    a    careful 


Fig.  310. — Backward  dislocation  of  radius  and  ulna  (skiagraph  by  Stanley  F.  Kent  and 

Edwin  White). 

consideration  of  the  distinctive  features  of  each  as  above  detailed ; 
but  it  must  be  borne  in  mind  that  the  various  signs  on  inspection 
and  palpation  are  often  much  obscured  by  surrounding  swelling 
of  the  soft  parts,  especially  when  the  displacement  is  the  result  of 
direct  violence.  The  most  important  point  is  the  careful  comparison 
of  the  relation  of  the  bony  prominences  around  the  articulation, 
both  on  the  sound  and  on  the  injured  side.  The  special  difficulty 
in  these  dislocations  arises  from  their  frequent  association  with  fract- 
ures, especially  of  the  epicondyles  of  the  humerus.  The  presence 
of  a  fracture  is  evidenced  by  the  ordinary  signs  of  abnormal  mobility 


634 


INTERNATIONAL     TEXT-BOOK  OF  SURGERY. 


— crepitus  and  fixed  local  pain  ;  but  these  signs  may  coexist  with  evi- 
dent signs  of  dislocation,  such  as  interference  with  the  general  mobility 
of  the  joint,  and  a  general  disturbance  of  the  normal  relationship  of 
the  bony  landmarks. 

One  of  the  most  common  sources  of  confusion  is  a  separation  of  the  combined  lower 
epiphysis  of  the  humerus.  To  distinguish  this  from  a  posterior  dislocation  of  the  radius 
and  ulna,  it  suffices  to  keep  the  following  points  in  mind  :  (if)  The  relative  position  of  the 
olecranon  and  condyles  is  unchanged;  ( b )  the  arm  is  shortened;  (<)  movement  causes 
much  pain,  is  abnormally  free,  is  accompanied  by  crepitus;  and  (i/)  reduction  of  the 
deformity  is  followed  by  recurrence  when  traction  is  discontinued.  Again,  the  anterior 
prominence  in  the  case  of  fracture  is  above  the  level  of  the  elbow-crease,  and  is  very 
tender  on  pressure.  Lastly,  it  is  important  to  decide  in  some  instances  whether  a  disloca- 
tion is  a  recent  or  an  old  one.  A  careful  attention  to  the  history  is  here  of  the  first  impor- 
tance. The  elbow  is  the  joint,  however,  in  which  the  employment  of  the  A'-rays  is  espe- 
cially likely  to  be  of  decided  utility  (Fig.  310). 

Prognosis. — With  regard  to  the  question  of  immediate  reduction, 
the  prognosis  in  dislocation  of  the  elbow  may  be  said  to  be  especially 
good,  all  forms  giving  little  trouble.  As  the  complete  outward  and  the 
divergent  forms  are  accompanied  by  extensive  rupture  of  the  ligaments, 
they  are  the  most  likely  to  leave  a  certain  want  of  security  behind 
them.     The  most  important  factor  in  the  prognosis  is  the  coexistence 

of  fracture,  which  often  leads  to 
deformity,  limitation  of  move- 
ment, or  even  complete  anky- 
losis, as  the  result  of  inexact 
healing  of  the  fragments  or  the 
formation  of  superabundant  cal- 
lus. Again,  the  inclusion  of 
either  the  ulnar,  posterior  inter- 
osseous, or  rarely  the  median 
nerve  in  such  callus  may  lead 
to  a  bad  functional  result. 

Treatment. — The  best  gen- 
eral method  of  reduction  is  that 
of  Cooper.  The  patient  and 
surgeon  place  themselves  in  the 
position  indicated  in  Fig.  311. 
In  the  posterior  dislocations 
both  hands  may  be  applied  to 
the  forearm  for  purposes  of  trac- 
tion ;  when  lateral  deviations 
exist,  the  second  hand  or  the 
hands  of  an  assistant  may  be 
necessary  to  make  direct  press- 
ure on  the  lateral  aspects  of  the 
joint.  The  knee  is  so  placed  in 
the  flexure  of  the  elbow  as  to 
support  the  humerus  and  at  the 
same  time  to  press  firmly  against 
the  forearm  to  disengage  the 
coronoid  process.  Traction  followed  by  flexion  is  then  made  in  the 
axis  of  the  forearm,  and  the  bones  usually  slip  into  position  with  a 
sensation  of  false  crepitation  or  a  distinct  snap. 


Fig.  311. — Reduction  of  dislocation  of  the 
elbow  by  Cooper's  method. 


SPECIAL   DISLOCATIONS.  635 

In  posterior  displacements,  if  difficulty  occurs,  the  joint  may  be 
hyperextended  so  as  to  disengage  the  coronoid  process  and  dilate  the 
rent  in  the  capsule.     The  elbow  is  then  flexed  under  traction. 

Forward  displacement  is  best  treated  by  Cooper's  method,  firm 
pressure  being  made  with  the  knee  against  the  forearm  ;  or  the  elbow 
may  be  flexed  by  an  assistant,  who  with  one  hand  makes  traction  in 
such  a  direction  at  the  upper  end  of  the  forearm  as  to  disengage  the 
olecranon  from  the  front  of  the  humerus,  while  with  the  second  hand 
the  patient's  hand  is  approximated  to  the  shoulder.  The  surgeon 
meanwhile  first  fixes  the  humerus,  and  then  attempts  to  guide  its 
progress  forward. 

In  the  lateral  deviations  reduction  is  often  facilitated  by  adducting 
the  arm  in  inward  displacements,  or  abducting  it  in  outward  ones 
— i.  e.\  by  repeating  the  movement  which  has  originally  given  rise  to 
the  dislocation,  and  thus  dilating  the  lateral  rent  in  the  capsule. 

In  the  divergent  variety  traction  in  the  axis  of  the  displaced  bones, 
followed  by  flexion  and  supination  for  the  reduction  of  the  radius,  is 
the  most  reasonable  method,  or  the  two  bones  may  be  reduced  indi- 
vidually. 

After  reduction  the  flexed  elbow  should  be  put  up  in  a  plaster-of- 
Paris  bandage  or  on  an  angular  splint,  and  kept  at  rest  for  at  least 
two  weeks.  The  splint  should  then  be  removed  for  exercise  and 
massage,  and  may  be  replaced  by  a  lighter  and  easily  movable  appli- 
ance. When  the  dislocation  is  accompanied  by  fracture,  especial  care 
is  necessary  to  prevent  ankylosis ;  and  here  the  general  rule  to  be 
observed  in  fractured  condyles  is  applied — namely,  to  commence  move- 
ment cautiously  as  soon  as  sufficient  callus  has  been  formed  to  unite 
the  fragments. 

Old'  Dislocations. — Attempts  should  be  made  to  reduce  these  at 
any  rate  up  to  the  end  of  six  months,  although  reduction  is  always 
extremely  difficult  after  the  lapse  of  six  weeks. 

The  difficult}7  in  uncomplicated  cases  depends  on  the  extremely 
complex  surface  offered  by  the  bones  of  the  articulation  ;  and  naturally 
those  cases  are  the  most  difficult  and  unpromising  in  which  the  proper 
conformation  has  been  distorted  by  fracture  of  one  or  more  of  the 
processes.  Subcutaneous  tenotomy  and  division  of  bands  are  prac- 
tically useless,  but  open  incision  and  the  removal  of  large  masses  of 
callus  or  badly  united  fragments  may  greatly  improve  the  functional 
capacity.  In  other  cases,  especially  where  there  is  deformity,  a  partial 
excision  is  indicated.  The  triceps  should  be  separated  with  the  olec- 
ranon and  both  turned  up ;  and  the  radio-ulnar  joint  should  always 
be  spared  if  possible.  The  olecranon  should  be  subsequently  wired. 
Removal  of  bone,  especially  of  the  humerus,  needs  to  be  very  free  in 
cases  of  abundant  callus-formation. 

Compound  Dislocation. — When  the  wound  is  small  or  a  mere  punct- 
ure by  the  bone,  pure  conservatism  and  asepticity  are  indicated.  If 
severe  and  contused,  a  partial  excision  with  the  view  of  providing 
efficient  drainage  may  give  a  better  chance  of  a  movable  joint.  Am- 
putation is  indicated  only  in  advanced  age,  general  constitutional 
defects,  or  extreme  local  destruction. 

Isolated  Dislocation  of  the  Ulna. — Either  extremity  of  the 


636  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

ulna  may  be  dislocated.  These  accidents  are,  however,  very  rare,  and, 
as  would  be  expected,  especially  that  affecting  the  upper  end.  A  large 
proportion  of  the  cases  are,  no  doubt,  really  incomplete  dislocations 
of  the  elbow. 

Upper  Extremity. — The  displacement  of  the  ulna  is  necessarily 
backward,  or  backward  and  somewhat  inward;  and  for  its  production 
violence  must  be  exerted  directly  on  the  upper  part  of  the  shaft  from 
before.  To  allow  the  dislocation,  the  internal  lateral  and  the  inner 
part  of  the  posterior  or  anterior  and  posterior  ligaments  of  the  elbow 
must  be  torn.  If  the  displacement  is  at  all  great,  the  orbicular  liga- 
ment also  must  be  detached,  or  the  external  lateral  ligament  must  be 
torn  or  set  free  by  fracture  of  the  external  cpicondyle. 

Symptoms. — The  forearm  is  either  slightly  flexed  or  extended — 
adducted — at  least  to  a  degree  destroying  the  normal  saliency  of  the 
inward  angle  of  the  junction  of  the  arm  and  forearm,  and  very  markedly 
pronated  to  allow  of  as  great  approximation  as  possible  of  the  carpus 
to  the  trochlea.  The  inner  margin  of  the  forearm  is  shortened  and 
thickened.  The  olecranon  is  prominent,  and  stretching  up  from  it  is 
the  tense  triceps  tendon.  On  palpation  the  olecranon  is  found  to  be 
higher  than  normal,  often  approximated  to  the  internal  condyle  later- 
ally. The  inner  condyle  is  obscured  by  the  adduction  of  the  forearm  ; 
the  external  is  prominent,  and  the  head  of  the  radius  is  felt  below  it. 
It  may  be  possible  to  feel  the  uncovered  trochlea  in  the  elbow-crease. 

Treatment. — The  displacement  may  be  reduced  in  the  manner 
already  described  in  the  case  of  the  elbow,  traction  and  extension 
being  combined  with  abduction  of  the  forearm.  The  after-treatment  is 
identical. 

Lower  Extremity. — This  dislocation  is  commonly  combined  with 
fracture  of  the  radius,  but  it  also  occurs  as  an  uncomplicated  condition. 
The  ulna  may  be  displaced  on  to  either  the  dorsal  or  the  palmar  aspect  of 
the  radius.  The  dislocation  is  usually  the  result  of  direct  force  exerted 
on  the  ulna,  the  radius  being  fixed  and  the  hand  extended.  Dorsal 
displacement  may  also  be  produced  by  forced  pronation  of  the  flexed 
wrist — palmar  by  forced  supination,  the  wrist  being  extended.  The 
triangular  fibrocartilage  is  separated  ;  the  anterior  and  posterior  inferior 
radio-ulnar  and  the  internal  lateral  ligaments  of  the  wrist  are  torn. 

Symptoms. — In  dorsal  displacement  the  hand  is  moderately  adducted, 
and  about  midway  between  pronation  and  supination,  occasionally 
inclining  to  one  or  other  of  the  latter  positions.  The  width  of  the 
wrist  is  decreased,  while  the  thickness  is  increased,  especially  at  the 
ulnar  side.  The  axis  of  the  ulna,  if  prolonged,  would  be  continued  to 
the  middle  finger.  On  palpation  the  styloid  process  is  absent  from  its 
position ;  the  head  of  the  ulna  may  lie  on  the  radius  or  even  on  the 
semilunar  bone.  On  manipulation,  supination  is  impossible,  and  flexion 
and  extension  are  very  painful. 

In  palmar  dislocation  the  hand  is  either  strongly  supinated  or  in  the 
mid-position  between  pronation  and  supination.  On  palpation  the 
head  is  felt  anteriorly,  and  there  is  a  hollow  posteriorly  over  the  cunei- 
form bone.     Either  of  these  dislocations  may  be  compound. 

Treatment. — To  reduce  the  dislocation  the  radius  must  be  fixed 
between  one   finger   and   thumb,  and   direct   pressure   made  with   the 


SPECIAL    DISLOCATIONS.  637 

other  thumb  on  the  head  of  the  ulna  ;  then,  in  the  case  of  the  dorsal 
displacement,  the  hand  should  be  supinated ;  in  the  palmar,  pronated. 
The  limb  should  be  fixed  on  a  splint  in  the  supine  position  if  the  dis- 
location has  been  dorsal,  or  the  reverse  if  palmar.  The  lower  end  of 
the  ulna  is  occasionally  rendered  abnormally  mobile  by  a  similar  acci- 
dent* to  that  producing  a  Colles  fracture,  but  without  any  antero- 
posterior shifting. 

Isolated  Dislocation  of  the  Radius. — The  isolated  displace- 
ment of  the  head  of  the  radius  is  far  more  easy  to  comprehend  than 
that  of  the  ulna,  still  the  majority  of  instances  are  properly  regarded  as 
incomplete  dislocations  of  the  elbow. 

Frequency  of  Occurrence. — In  the  St.  Thomas's  series  of  1207  dis- 
locations of  all  joints,  49  of  the  radiohumeral  occurred,  or  a  ratio  of 
4.05  percent.  In  Kronlein's  series  of  400,  15  occurred,  or  $.jj  per 
cent. 

Causation. — The  anterior  and  posterior  displacements  may  both  be 
occasioned  by  direct  violence  applied  to  the  aspect  of  the  forearm 
opposite  that  on  which  the  head  escapes,  or,  in  the  case  of  the  pos- 
terior dislocation,  by  force  applied  to  the  back  of  the  humerus,  the 
elbow  being  in  a  position  of  flexion.  The  larger  number  of  cases, 
however,  are  the  result  of  indirect  violence,  such  as  falls  on  the  hand 
and  traction  on  the  extended  supinated  forearm,  the  latter  especially 
in  children.  The  forward  dislocation  is  sometimes  due  to  muscular 
action,  as  has  been  observed  in  the  action  of  the  biceps  in  lifting  a 
heavy  weight,  or  in  forcible  movements  of  supination,  as  in  wringing 
out  clothes. 

The  head  of  the  radius  may  be  displaced  in  three  directions — viz., 
forward,  by  far  the  most  common  ;  backward ;  or  outward,  the  least 
common. 

Symptoms. — Certain  signs  are  common  to  all  three  varieties  and 
their  degrees:  1.  Shortening  and  vertical  increase  of  diameter  of  the 
radial  margin  of  the  forearm  ;  2.  Abduction  of  the  forearm  ;  3.  Conse- 
quent elevation  of  the  styloid  process  of  the  radius  ;  4.  Alteration  of 
the  axis  of  the  radius;  5.  Absence  of  the  head  of  the  bone  in  its 
normal  position  beneath  the  external  condyle ;  6.  A  certain  degree  of 
lateral  mobility  at  the  elbow. 

Forward  dislocation  may  be  complete  or  incomplete.  On  inspection 
the  elbow  is  found  one-quarter  flexed,  more  or  less  pronated  and 
abducted.  The  common  origin  of  the  extensor  muscles  of  the  forearm 
is  pushed  outward,  and  the  head  of  the  radius  may  be  visible,  as  well 
as  the  external  condyle,  in  spite  of  the  abduction.  The  internal  epi- 
condyle  is  abnormally  prominent,  the  hand  is  abducted,  and  the  axis 
of  the  radius  strikes  the  anterior  surface  of  the  humerus  (Figs.  312 
and  313).  On  palpation,  if  the  elbow  is  neither  fat  nor  swollen,  the 
head  of  the  radius  can  be  felt  anterior  to  the  external  condyle  of  the 
humerus,  covered  by  the  tense  biceps  tendon  and  fascia.  At  the 
bottom  of  the  hollow  in  the  normal  position  of  the  head,  the  ulna,  the 
lesser  sigmoid  cavity,  and  the  under  and  posterior  part  of  the  capitellum 
may  be  felt.  On  manipulation  the  elbow  can  neither  be  flexed  nor 
extended ;  in  the  former  movement  the  head  of  the  radius  strikes 
against  the  front  of  the  humerus.     Pronation  and  supination  are  very 


638 


INTERNATIONAL     TEXT- BOOK    OT  St  k'CERY. 


limited.     There  is  some    abnormal    lateral    mobility.      Paralysis   occa- 
sionally results  from  injur)-  to  the  posterior  interosseous  nerve. 

In  backward  dislocation,  the  elbow  is  slightly  flexed,  and  stands 
midway  between  pronation  and  supination.  ( )n  palpation  the  head  can 
be  felt  behind   and   above  the  external   epicondyle  ;  the   latter  can  be 


Fig.  312.—  Old  forward  dislocation  of  head  of  the  radius. 

mapped  out  as  to  its  outer  and  anterior  aspects,  and  below  it  a  hollow 
is  to  be  determined.  The  tense  biceps  tendon  may  be  distinguished  in 
the  inner  part  of  the  hollow.     On  manipulation,  no  extension  is  pos- 


"^r 


Fig.  313. — Forward  dislocation  of  head  of  the  radius,  showing  crossing  of  axis  of  the  bones 
(skiagraph  by  A.  B.  Blackei 

sible,  and  little  flexion.     Pronation  and  supination  are  also  practically 
abrogated,  especially  the  latter. 

In  outward  dislocation,  the  elbow  is  moderately  flexed  and  the  fore- 
arm pronated.  On  palpation  the  head  is  to  be  felt  above  and  to  the 
outer  side  of  the  external  epicondyle.     On  manipulation,  flexion  and 


SPECIAL    DISLOCATIONS.  639 

extension  are  painful  and  difficult,  but  less  limited  than  in  the  other 
varieties.  Supination  is  interfered  with.  When  there  is  coexisting 
fracture  of  the  upper  third  of  the  ulna,  the  whole  forearm  is  shortened, 
and  mobility  is  naturally  greater. 

Diagnosis. — A  differential  diagnosis  is  readily  made  by  attention 
to  the  points  above  enumerated.  It  must  be  borne  in  mind,  however, 
that  the  displacements,  both  forward  and  backward,  are  occasionally 
incomplete,  and  under  these  circumstances  the  signs,  though  of  the 
same  nature,  are  less  strongly  marked.  In  the  forward  dislocation  the 
impossibility  of  complete  flexion  is  the  most  valuable  diagnostic  aid. 

Treatment. — Forward  Dislocation. — The  forearm  should  be  flexed 
to  relax  the  biceps  and  pronator  radii  teres,  the  forearm  adducted  to 
lower  the  head,  and  then  extended  and  supinated,  firm  direct  pressure 
being  made  at  the  same  time  on  the  displaced  head.  If  this  maneuver 
fail,  hyperextension  combined  with  adduction  and  direct  pressure  may 
be  tried.  The  limb  is  best  put  up  either  very  fully  flexed  in  plaster  of 
Paris,  or  extended,  with  a  pad  over  the  head  of  the  radius. 

In  posterior  dislocation,  traction  is  made  on  the  extended  supinated 
forearm,  followed  by  pronation,  and  accompanied  by  direct  pressure 
and  abduction.     The  limb  should  then  be  put  in  a  position  of  flexion. 

In  outward  dislocation,  extension,  abduction,  and  supination  are 
made,  with  direct  pressure  downward  and  inward.  The  limb  is  put  up 
in  a  flexed  position. 

When  efforts  fail  to  reduce  one  of  these  dislocations,  the  joint  may  be  opened  and  an 
attempt  at  reposition  made.  This  is  often  by  no  means  easy,  and  then  has  failed  to 
effect  permanent  retention.  For  this  reason  a  temporary  suture  passed  through  the  head 
and  the  capitellum  and  retained  for  fourteen  days  has  been  employed  with  success  by  Bar- 
denheuer.  Should  the  reposition  of  the  head  prove  impossible,  it  should  be  resected,  but 
great  care  will   still   be  needed   to  ensure  a  movable  joint. 

Subluxation  of  the  Head  of  the  Radius. — In  early  childhood 
a  condition  to  which  the  above  name  is  applied  results  from  forcible 
dragging  on  the  forearm,  often  by  the  nurse,  or  in  play.  It  is  probably 
explained  by  the  normal  laxity  of  the  orbicular  ligament  in  children, 
already  referred  to,  and  to  want  of  full  development  of  the  head  of  the 
radius.  It  has  been  ascribed  to  a  slight  displacement  downward  of  the 
head  of  the  radius  together  with  the  formation  of  a  fold  of  the  ligaments, 
which  becomes  interposed  between  the  back  of  the  head  and  the  capi- 
tellum. In  connection  with  this  theory,  the  normal  projection  of  the 
synovial  and  subsynovial  tissue  as  a  ring,  resembling  an  incomplete 
meniscus,  around  the  head  of  the  radius  may  be  mentioned,  since 
swelling  of  this  segment  of  the  synovial  capsule  might  produce  an 
identical  condition.  J.  Hutchinson,  Jr.,  considers  the  deformity  due  to 
the  head  of  the  radius  slipping  out  of  the  grasp  of  the  orbicular  liga- 
ment. Fracture  of  the  neck  of  the  radius  has  proved  the  explanation 
of  a  corresponding  deformity  in  some  cases  ;  displacement  of  the  infe- 
rior radio-ulnar  fibrocartilage  also  produces  similar  signs. 

The  forearm  is  held  flexed  in  a  prone  position,  or  midway  between 
a  prone  and  supine  position.  Supination  is  very  painful.  The  signs 
may  be  removed  by  complete  supination  followed  by  flexion,  under  an 
anesthetic  if  necessary.  The  forearm  should  then  be  placed  in  a  sling, 
and  massage  and  careful  exercise  employed. 


64O  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

CarpUS. — The  articulation  of  the  wrist  owes  its  security  to  the  fact 
that  it  is  surrounded  by  a  large  number  of  tendons,  and  that  these  in 
addition  are  held  in  close  and  firm  relationship  with  it  by  the  so-called 
annular  ligaments. 

Anteriorly  ami  posteriorly  there  is  no  bony  prominence  beyond  that  provided  by  the 
slight  concavity  of  the  lower  end  of  the  radius  ;  and  as  to  tin-  capsule,  the  posterior  aspect 
i^  decidedly  the  weaker.  Laterally  the  influence  of  tendons  is  less  marked  ;  but  here 
beyond  the  strong  lateral  ligaments  we  have  the  projecting  styloid  processes.  The  articu- 
lation is  essentially  one  between  the  carpus  and  radius  ;  hence  we  find  all  the  provisions  are 
directed  to  the  maintenance  of  these  two  elements  in  contact.  Thus,  the  styloid  process  of 
the  radius  projects  lower  ;  the  direction  of  the  libers  of  both  the  anterior  and  posterior  liga- 
ments is  from  the  radius  downward  and  inward.  In  full  flexion,  and  especially  extension, 
the  hand  is  drawn  to  the  radial  side,  so  that  the  fingers  are  adducted  ;  and  adduction  is  a 
free  movement  limited  by  tension  of  the  soft  structures  only,  while  abduction  which  would 
throw  the  carpus  against  the  small  lower  end  of  the  ulna  is  strictly  limited  by  the  bony  con- 
tact of  the  styloid  process  of  the  radius  with  the  scaphoid  bone. 

Frequency  of  Occurrence. — Luxations  of  the  wrist  are  extremely 
rare.  Thus,  in  the  largest  collection  of  cases  which  was  compiled  from 
general  literature  by  Parker  in  1 871,  only  33  were  included;  and  in 
Kronlein's  statistics  we  find  only  1  example.  In  the  St.  Thomas's 
series,  however,  dislocation  of  the  wrist  is  said  to  have  occurred  13 
times  among  1207  dislocations,  of  all  joints,  a  ratio  of  1.07  per  cent. 

Causation. — The  rarity  of  the  injury  is  no  doubt  accounted  for  by 
the  shortness  of  the  lever  formed  by  the  hand,  and  the  greater  fre- 
quency of  fracture  of  the  radius.  It  is  ordinarily  the  result  of  indirect 
violence,  most  commonly  a  fall  on  the  outstretched  palm,  in  a  position 
of  full  pronation  and  extension,  which  therefore  causes  also  some 
deflection  to  the  ulnar  side.  The  hand  becomes  the  fixed  point,  and 
the  bones  of  the  forearm  press  down  to  the  ground,  so  that  the  carpus 
is  displaced  on  to  their  dorsal  aspect.  The  opposite  displacement  may 
be  produced  by  a  fall  on  the  flexed  wrist.  Anterior  dislocation  has 
been  observed  as  a  result  of  hyperextension.  Occasionally  the  acci- 
dent is  due  to  direct  violence.  The  dorsal  and  palmar  are  the  only 
two  recognized  uncomplicated  dislocations,  and  of  these  the  dorsal  is 
twice  as  frequent  as  the  palmar. 

Pathology. — The  anterior  and  posterior  ligaments  are  usually  extensively  torn  ;  the 
external  lateral  also  is  usually  torn  through,  or  the  radial  styloid  process  separated.  The 
internal  lateral  ligament  often  escapes.  The  radial  styloid  process  is  the  one  most  often 
injured.  In  the  dorsal  dislocation  the  extensor  tendons  are  lifted  from  their  grooves,  carry- 
ing with  them  the  attachments  of  the  annular  ligament  to  the  bone  ;  and  they  are  displaced 
more  or  less  to  the  radial  and  ulnar  sides. 

Symptoms. — In  backward  dislocation  the  elbow  is  flexed,  the  fore- 
arm in  a  position  midway  between  pronation  and  supination.  The 
wrist  itself  takes  up  no  definite  position,  but  may  be  deflected  in  either 
of  the  four  angular  directions.  The  fingers  are  flexed  at  the  meta- 
carpophalangeal joints,  and  the  interphalangeal  joints  are  extended. 
A  steep,  transverse,  dorsal  prominence  exists,  and  on  the  palmar  aspect 
a  less  marked  palmar  projection,  reaching  well  down  to  the  base  of 
the  thumb.  The  long  axis  of  the  hand  crosses  that  of  the  forearm. 
On  palpation  the  styloid  processes  bear  their  normal  relationship  to 
each  other,  are  in  the  axis  of  the  forearm,  and  before  the  convex  dorsal 
prominence  of  the  carpus.  The  articular  surface  of  the  radius  is 
obscured  anteriorly  by  the   flexor  tendons,  which   dip  sharply  back- 


SPECIAL   DISLOCATIONS.  64 1 

ward  to  pass  beneath  the  annular  ligament.  On  manipulation,  all 
movements  are  interfered  with.  Measurement  shows :  [a)  the  length 
of  the  radius  from  its  head  to  the  tip  of  the  styloid  process  to  be  equal 
to  that  of  the  opposite  limb ;  (/;)  the  distance  from  the  upper  margin 
of  the  dorsal  prominence  to  the  tip  of  the  middle  finger  to  equal  that 
from  the  line  of  the  radiocarpal  joint  to  the  same  point. 

In  forward  dislocation,  the  dorsal  prominence  is  concave  from  side 
to  side,  and  in  a  recent  injury  the  styloid  processes  are  visible.  The 
palmar  prominence  is  convex  upward,  and  somewhat  obscured  by  the 
thickness  of  the  flexor  tendons.  On  palpation  and  measurement,  the 
signs  resemble  those  already  detailed  in  the  case  of  the  dorsal  displace- 
ment, except  in  regard  to  the  reversal  of  the  top  level  of  the  prominences 
(the  palmar  being  the  higher),  the  concave  outline  of  the  dorsal  promi- 
nence, and  the  possibility  of  tracing  the  outline  of  the  radio-ulnar  arch. 

Diagnosis. — If  the  points  above  detailed  under  the  heading  of 
Symptoms  be  borne  in  mind,  no  difficulty  should  occur  in  the  veri- 
fication of  this  injury.  Colles's  fracture  and  separation  of  the  lower 
radial  epiphysis  are  the  only  stumbling-blocks ;  and  confusion  with 
either  of  these  is  readily  avoided  by  attention  to  the  relative  position 
of  the  bony  landmarks. 

Prognosis. — Reduction  is  easy,  and,  in  spite  of  the  shallowness  of 
the  joint-cavity,  no  marked  disposition  to  recurrence  has  been  observed. 

Treatment. — The  displacement  is  readily  reduced  by  traction  in  the 
axis  of  the  displaced  hand,  combined  with  direct  pressure  on  the  dorsal 
or  palmar  prominence,  as  the  case  may  be.  The  hand  and  forearm 
should  then  be  placed  on  anterior  and  posterior  splints,  well  padded 
opposite  the  position  of  the  late  carpal  prominence,  the  fingers  being 
allowed  to  project,  so  as  to  guard  against  subsequent  stiffness  from 
fixation  of  the  tendons.  After  fourteen  days  the  splint  should  be 
removed  daily,  the  hand  and  forearm  massaged,  and  careful  move- 
ment of  the  fingers  carried  out.  The  splints  should  be  retained  for 
four  to  five  weeks,  and  in  many  cases  may  be  with  advantage  super- 
seded by  a  leather  gauntlet  to  be  worn  for  a  further  period. 

Compound  dislocations  should  be  treated  as  conservatively  as  pos- 
sible. A  loose  carpal  bone  may  need  removal,  or  in  some  cases  a 
partial  resection  may  be  advantageous ;  but  amputation  should  be 
decided  on  only  in  the  case  of  hopeless  injury,  or  in  a  patient  wholly 
unfit  to  take  the  risks  of  the  process  of  healing. 

Dislocation  of  the  Individual  Bones  of  the  Carpus. — Of  the  first 
row,  the  pisiform  is  occasionally  displaced  by  the  action  of  the  flexor 
carpi  ulnaris  or  by  direct  violence.  The  bone  usually  acquires  fresh 
attachment,  and  the  injury  is  of  little  importance.  The  scaphoid  and 
semilunar  have  also  been  seen  to  be  dislocated,  usually  in  compound 
injuries.     In  such  a  case  the  displaced  bone  may  be  removed. 

Of  the  second  row,  the  os  magnum  is  most  frequently  displaced — 
seldom  completely,  however,  the  head  and  neck  only  projecting  dorsal- 
ward  as  a  result  of  the  rupture  of  the  transverse  ligament  which 
crosses  from  the  scaphoid  to  the  cuneiform.  This  portion  of  the  os 
magnum  sometimes  acquires  a  prominence  as  a  result  of  habitual 
strain  due  to  the  occupation  of  the  individual.  In  traumatic  disloca- 
tion it  is  best  reduced  by  direct  pressure,  the  middle  finger  being  at 

41 


642  INTERNATIONAL    TEXTBOOK   OF  SURGERY. 

the  same  time  drawn  upon.  If  painful  and  irreducible,  it  may  be 
removed. 

Separation   of  the  two  rows  of  the  carpus  is  very  rare. 

Metacarpus. — The  fixity  of  the  carpometacarpal  junction  makes 
dislocation  of  these  bones  one  of  the  rarest  occurrences.  As  would 
be  expected  from  the  mobility  and  exposed  position  of  the  metacarpal 
bone  of  the  thumb,  the  first  bone  is  the  one  most  commonly  displaced ; 
and  this  will  be  treated  of  specially.  Of  the  others,  the  second  and 
third  are  most  exposed  by  reason  of  their  comparative  length.  Most 
of  the  recorded  instances  have  been  of  the  first  finger.  A  case  is 
figured  in  Erichsen's  Surgery,  in  which  the  four  bones  were  apparently 
dislocated  en  masse. 

Symptoms. — On  inspection  there  appears  either  a  dorsal  promi- 
nence or  a  hollow  bounded  by  the  line  of  the  second  row  of  carpal 
bones,  according  to  whether  the  metacarpal  bone  has  passed  backward 
or  forward.  The  finger  is  shortened  and  slightly  flexed.  In  Erichsen's 
case  the  fingers  are  extended  and  abducted.  On  palpation  the  above 
points  will  be  corroborated. 

Apart  from  complete  traumatic  dislocation  of  these  bones,  it  should  be  mentioned  that 
the  bases  of  the  bones,  especially  the  third,  are  occasionally  partially  displaced  backward, 
and  form  a  dorsal  prominence  bounding  a  slight  hollow.  Such  displacements  may  follow  a 
fall  on  the  hand,  or  are  the  result  of  hard  manual  labor.  They  usually  do  not  call  for 
treatment. 

Recent  traumatic  dislocations  are  to  be  reduced  by  traction  on  the 
corresponding  finger  or  fingers,  combined  with  direct  pressure  down- 
ward and  forward,  or  backward,  as  the  case  may  be. 

Metacarpal  Bone  of  the  Thumb. — The  joint  between  this  bone  and 
the  trapezium  differs  from  the  others  not  only  in  its  greater  mobility 
as  to  flexion  and  extension,  but  also  in  possessing  free  lateral  move- 
ment. Displacement  may  be  dorsal  or  palmar,  and  usually  results 
from  falls  on  the  palm  of  the  hand,  leading  to  hyperextension ;  but  it 
may  be  caused  by  forcible  flexion  with  adduction. 

Symptoms. — In  dorsal  dislocation  the  wrist  and  the  phalanges  of 
the  thumb  are  slightly  flexed,  a  prominence  is  seen  on  the  dorsum  of 
the  carpus  slightly  internal  to  the  normal  position  of  the  base  of  the 
bone,  and  the  tabatiere  anatomique  is  deepened.  The  thumb  is  short- 
ened. On  palpation  the  base  of  the  metacarpal  bone  is  approximated 
to  the  styloid  process  of  the  radius.  The  displacement  may  be  incom- 
plete, when  these  signs  will  be  less  strongly  marked. 

Palmar  dislocation  is  rarer  than  the  dorsal.  A  hollow  takes  the 
place  of  the  prominence  mentioned  in  the  last  form,  while  the  base  of 
the  metacarpal  bone  may  be  felt  on  the  palmar  aspect  of  the  trapezium. 
The  thumb  is  extended,  and  opposition  is  impossible.  The  phalanges 
may  be  moved  freely. 

Treatment. — The  dislocation  is  readily  reduced  by  traction  in  the 
axis  of  the  displaced  bone,  combined  with  direct  pressure  on  the  base 
in  a  downward  direction,  and  either  forward  or  backward,  as  the  case 
may  be.  If  this  fails,  hyperextension  may  be  tried  ;  also  hyperextension 
combined  with  direct  pressure.  The  thumb  should  then  be  fixed  in  a 
position  of  full  extension,  with  a  pad  over  the  base  of  the  metacarpal 
bone. 


SPECIAL    DISLOCATIONS.  643 

Metacarpophalangeal   and   Interphalangeal  Joints. — The 

joints  between  the  metacarpus  and  the  phalanges,  and  the  interphalan- 
geal joints  in  a  less  degree,  are  peculiar  in  the  nature  of  the  ligament 
forming  the  anterior  segment  of  the  capsule.  This  consists  of  a  fibro- 
cartilaginous plate,  loosely  attached  to  the  proximal  bone,  but  firmly 
blended  with  the  base  of  the  distal  one.  This  arrangement,  while 
scarcely  disposing  to  the  occurrence  of  dislocation,  forms  a  difficulty 
in  the  reduction  of  the  phalanx,  since  the  plate,  especially  in  the  case 
of  the  metacarpophalangeal  joint,  is  apt  to  be  actually  drawn  over  the 
head  of  the  proximal  bone,  and  to  interpose  itself  between  the  dis- 
placed bones.  The  tenuous  dorsal  segment  of  the  capsule  offers  little 
obstacle  to  displacement. 

Thumb. — The  metacarpophalangeal  joint  of  the  thumb  must  be 
considered  alone.  In  the  other  joints  four  angular  movements  are 
possible ;  in  the  case  of  the  thumb  lateral  movements  are  shifted  one 
segment  back,  giving  greater  range  with  a  shorter  digit,  and  at  the 
same  time  endowing  the  distal  joint  with  the  fixity  necessary  for  its 
safety.  Beyond  this  the  glenoid  plate  consists  of  two  sesamoid  bones 
and  an  intervening  bond,  an  arrangement  in  part  responsible  for  the 
difficulties  met  with  in  the  reduction  of  dislocations  of  this  articulation. 

In  1207  dislocations  met  with  at  St.  Thomas's  Hospital,  88  were  of  the  thumb,  or  7.29 
percent.  The  88  were  distributed  as  follows  :  Carpometacarpal,  10;  metacarpophalangeal, 
47  ;   interphalangeal,  31.     In  Kronlein's  statistics  the  percentage  amounted  to  6.7. 

Causation. — In  the  commoner  or  dorsal  dislocation  the  accident  is 
usually  the  result  of  a  fall  on  the  outstretched  palm.  The  palmar 
dislocation  may  be  caused  by  violent  flexion  or  direct  violence. 

Pathology. — The  dorsal  dislocation  may  be  complete  or  incomplete.  In  the  former  the 
capsule  suffers  injury  to  the  glenosesamoid  plate,  which  is  torn  from  its  connection  to  the 
metacarpal  bone  ;  and  the  anterior  parts  of  the  lateral  ligaments,  especially  the  outer,  are 
usually  torn  also.  The  dorsal  ligament  may  escape,  but  is  ruptured  if  the  phalanx  passes 
far  on  to  the  dorsum  of  the  metacarpal  bone.  Little  injury-  is  suffered  by  the  short  muscles 
of  the  thumb,  the  outer  head  of  the  flexor  brevis  pollicis  being  the  only  one  torn,  and  this 
in  its  anterior  part,  and  not  sufficiently  to  separate  it  from  its  sesamoid  bone.  The  tendon 
of  the  long  flexor  is  usually  displaced  inward,  lying  behind  the  prominence  of  the  head  of 
the  metacarpal  bone,   on  the  expansion  of  the  short  muscles. 

The  difficulty  experienced  in  the  reduction  of  this  dislocation  has  been  variously  attrib- 
uted to  the  tight  grasping  of  the  neck  of  the  metacarpal  bone  by  the  slit  in  the  capsule,  to 
the  contraction  of  the  short  muscles  and  a  similar  gripping  of  the  head  between  them,  and 
to  the  interposition  of  the  capsule  or  parts  of  it  between  the  joint-surfaces.  Of  these  three 
explanations,  it  is  not  possible  to  exclude  entirely  the  first  two  ;  but  they  appear  to  have 
depended  on  an  incomplete  attention  to  the  peculiarities  of  the  anterior  segment  of  the 
capsule.  From  what  has  been  already  said  it  will  be  seen  that  the  primary  gap  in  the  cap- 
sule depends  on  the  separation  of  the  glenoid  ligament  from  the  metacarpal  bone — that  is, 
a  transverse  slit  at  the  proximal  part  of  the  joint.  In  the  incomplete  dislocations  the  sep- 
arated margin  is  drawn  on  to  the  head  of  the  metacarpal  bone,  together  with  the  sesa- 
moid bones,  but  does  not  pass  the  point  of  greatest  convexity  of  the  head.  In  this  condi- 
tion no  difficulty  in  reduction  is  likely  to  arise.  In  the  complete  dislocations,  rupture  of 
the  anterior  parts  of  the  lateral  ligaments,  particularly  the  external,  enlarges  the  gap  ;  and 
this  may  be  further  increased  by  a  vertical  separation  of  the  two  sesamoid  bones.  The 
freed  margin  of  the  glenosesamoid  plate  now  crosses  the  dorsal  aspect  of  the  head,  and 
forms  an  actual  septum  between  the  margin  of  the  phalanx  and  the  joint-cavity.  When 
unsuccessful  efforts  at  reduction  are  made,  one  of  two  things  occurs — either  the  glenosesa- 
moid plate  is  bent  sharply  backwaixi  at  its  point  of  union  with  the  phalanx,  and  covers  its 
concave  base,  forming  a  wedge  which  prevents  the  return  of  the  bones  into  position  by 
greatly  increasing  the  tension  of  the  lateral  ligaments  ;  or,  in  the  movement  of  flexion,  the 
rdenosesamoid  plate  is  flattened  out  on  the  dorsum  of  the  metacarpal  bone  by  the  pull  of 
the  short  flexor  muscles,  its  anterior  smooth  surface  resting  on  the  bone,  and,  the  sesamoid 
bones  being  rotated  so  that  their  cartilaginous  surfaces  look  backward  and  outward,  the 


644 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


phalanx  assuming  the  extended  position,   with   corresponding   shortening  of    the   thumb. 
Further  efforts  at  reduction  now  only  tend  to  the  production  of  the  first  condition  described. 

Symptoms. — In  dorsal  dislocation  the  thumb  is  flexed  at  the  meta- 
carpophalangeal joint;  if  the  dislocation  is  incomplete,  to  an  obtuse 
angle;  if  complete,  to  a  right  angle.  In  the  latter  case  the  thumb  is 
shortened;  the  distal  phalanx  is  usually  flexed  and  difficult  to  extend. 
The  phalangeal   section  is  also  commonly  somewhat  adducted.     The 

head  of  the  metacarpal  bone  forms 
a  palmar  prominence.  On  palpa- 
tion the  head  of  the  metacarpal 
bone  can  be  felt  anteriorly,  and 
the  base  of  the  phalanx  on  its  pos- 
terior aspect.  Care  must  be  taken 
not  to  mistake  the  wide  base  of 
the  phalanx  for  the  metacarpal 
head — an  error  which  has  been 
made  when  the  parts  were  obscured 
by  much  surrounding  swelling. 
A  continuance  of  the  violence  or 
efforts  at  reduction  may  some- 
times result  in  the  further  dis- 
placement mentioned  under  the 
heading  of  Pathology.  The  pha- 
lanx is  then  extended  and  parallel 
to  the  metacarpal  bone  ;  there  is 
considerable  shortening,  the  base 
of  the  phalanx,  sometimes  reach- 
ing as  far  as  the  middle  of  the 
metacarpal  shaft ;  and  the  vertical 
diameter  of  the  thumb  is  nearly 
doubled. 

Palmar  dislocation  is  very  rare.  It  is  usually  the  result  of  direct 
violence.  The  dorsal  aspect  of  the  capsule  is  torn,  and  the  glenosesa- 
moid  plate  separated  from  the  metacarpal  bone.  On  inspection  the 
proximal  phalanx  is  usually  flexed,  and  this  position  is  combined  with 
some  vertical  rotation  of  the  thumb,  due  to  the  inability  of  the  convex 
oval  margin  of  the  phalanx  to  rest  exactly  on  the  convex  metacarpal 
head  (Bardenheuer),  and  also  to  slight  adduction.  The  distal  phalanx 
is  extended.  The  long  extensor  tendons  cross  the  angle,  or  are  some- 
times interposed.  On  palpation,  the  head  of  the  metacarpal  bone  is 
readily  mapped  out,  and  a  corresponding  gap  in  front  of  it.  The  base 
of  the  phalanx  may  be  felt  anteriorly. 

Diagnosis. — The  differential  diagnosis  depends  on  a  careful  atten- 
tion to  the  points  above  detailed.  It  should  be  remembered  that  dis- 
locations of  the  thumb  are  generally  accompanied  by  much  immediate 
swelling  and  subsequent  local  inflammation. 

Prognosis. — The  difficulties  of  reduction  in  certain 'cases  have  been 
already  alluded  to,  and  will  find  further  mention  under  the  heading  of 
Treatment.  The  anterior  dislocations  are  difficult  to  retain  in  position. 
If  either  dislocation  remains  unreduced,  the  function  gradually  improves 
with  time  and  use,  and  may  be  fair. 


Fig.  314. — Dislocation  of  the  thumb. 


SPECIAL   DISLOCATIONS.  645 

Treatment. — In  dorsal  displacements  this  consists  in  hyperextension. 
The  base  of  the  phalanx  is  pushed  forward  by  one  thumb  of  the  oper- 
ator, while  the  tip  is  forcibly  pressed  upon  by  the  other,  so  as  to  tilt 
the  base  over  the  head  of  the  metacarpal  bone  without  danger  of  inter- 
posing the  glenosesamoid  plate.  Some  adduction  may  be  combined, 
if  necessary,  to  utilize  the  generally  wider  tearing  of  the  external  lateral 
ligament.  The  older  method  of  primary  flexion  of  the  metacarpal 
bone  together  with  traction  and  direct  pressure  is  less  satisfactory,  as 
more  likely,  by  releasing  and  altering  the  direction  of  the  pull  of  the 
short  muscles,  to  allow  of  interposition  of  the  glenosesamoid  plate. 
In  troublesome  cases  Mr.  J.  Hutchinson,  Jr.,  enters  a  small  tenotome 
immediately  above  the  base  of  the  displaced  phalanx  and  divides  the 
sphenoid  plate  between  the  sesamoid  bones,  which  he  states  renders  reduc- 
tion easy.  The  method  proposed  by  Palmer,  of  making  a  small  opening 
on  the  palmar  surface  for  the  introduction  of  a  lever  across  the  head  of 
the  metacarpal  bone  and  beneath  the  base  of  the  phalanx,  is  also  worthy 
of  trial.  In  palmar  dislocations  the  thumb  should  be  fully  flexed  and 
direct  backward  pressure  made  on  the  base  of  the  phalanx,  while  the 
head  of  the  metacarpal  bone  is  pressed  in  an  opposite  direction. 

Lastly,  if  the  dislocation  defies  ordinary  methods,  the  best  resort  is 
arthrotomy  with  a  radial  incision.  Subcutaneous  tenotomy  has  been 
recommended  and  much  employed — often,  however,  unsuccessfully, 
as  might  be  expected  if  the  glenosesamoid  plate  is  the  chief  cause  of 
difficulty.  If  arthrotomy  fails,  excision  of  the  head  gives  very  good 
results ;  but  it  is  usually  demanded  by  old  cases  only.  In  dislocations 
of  the  thumb  even  the  interval  of  a  few  days  is  of  great  prognostic 
importance,  as  far  as  reduction  is  concerned.  Compound  dislocations 
are  to  be  treated  conservatively,  resection  being  admissible  only  in 
special  cases.     Good  results  are  generally  obtained. 

Metacarpophalangeal  Joints  of  the  Fingers. — Dislocations  of  these 
joints  are  uncommon,  although  not  so  rare  as  old  statistics  would  lead 
us  to  believe.  Thus,  of  1207  dislocations  of  all  joints  observed  at  St. 
Thomas's  Hospital,  103,  or  8.53  per  cent,  were  of  the  fingers.  These 
were  distributed  as  follows  :  Carpometacarpal,  7  ;  metacarpophalangeal, 
30;   first  interphalangeal,  35  ;  second  interphalangeal,  31. 

These  joints  differ  from  that  of  the  thumb  in  the  possession  of 
lateral  mobility,  and  in  the  anterior  ligament  being  a  simple  glenoid 
plate  without  sesamoid  bones.  Dislocation  is  most  commonly  dorsal, 
rarely  palmar,  and  in  the  case  of  the  index  and  little  fingers  lateral  dis- 
placement has  occasionally  been  observed.  The  ring  finger  is  very 
rarely  dislocated. 

Symptoms. — The  signs  vary  only  slightly  in  degree  and  in  the  dif- 
ferent outline  of  the  joint  from  those  already  detailed  fully  in  the  case 
of  the  thumb,  and  the  same  methods  of  reduction  may  be  tried. 

Interphalangeal  Joints. — The  anatomy  of  these  joints  resembles 
that  of  the  metacarpophalangeal,  varying  only  in  the  lesser  degree  of 
strength  and  in  the  presence  of  a  double  condylar  head  to  the  pha- 
langes. The  dorsal  and  palmar  displacements  are  accompanied  by 
precisely  similar  signs  to  those  observed  in  the  proximal  joints. 

The  special  variety  of  dislocation  is  the  partial  lateral  one.  This  is 
due  to  lateral  flexion  of  the  joint,  leading  to  rupture  of  one  lateral  liga- 
ment and  the  escape  of  the  phalanx  to  the  corresponding  side,  the 


646  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

inner  condyle  of  the  proximal  phalanx  resting  in  the  outer  cavity  at 
the  base  of  the  distal  phalanx,  or  vice  versa,  as  the  case  may  be.  These 
dislocations  arc  unaccompanied  by  shortening  or  by  marked  flexion. 
The  finger  is  usually  extended,  the  long  axis  is  distorted,  and  lateral 
prominences  are  to  be  felt  corresponding  to  the  uncovered  condyle  of 
the  proximal  phalanx  and  the  base  of  the  distal  one.  All  are  best 
treated  by  traction  and  direct  pressure  on  the  displaced  bone.  What 
has  been  said  as  to  the  treatment  of  compound  dislocation  of  the 
thumb   holds  good  here. 

Tibia. — According  to  the  general  mode  of  classification,  disloca- 
tions of  the  knee  are  regarded  as  displacements  of  the  tibia  ;  but  it 
should  be  pointed  out  that  in  all  cases  it  is  the  femur  which  bursts  the 
capsule,  and  therefore  takes  the  more  active  part  in  the  production  of 
the  injury. 

As  the  central  joint  of  the  long  lever  formed  by  the  lower  extremity,  the  knee  has  to 
withstand  greater  strain  than  any  other  articulation  in  the  body.  Its  power  to  do  this 
depends  on  several  special  characteristics.  In  the  first  place,  the  bony  contact  exceeds  in 
surface-area  that  of  any  other  joint  in  the  body.  A  very  shallow  cavity  is,  however,  offered 
by  the  tuberosities  of  the  tibia — a  point  of  importance  as  to  the  possible  occurrence  of  dis- 
location, since  no  bony  prominence  exists  to  act  as  an  abnormal  fulcrum  in  forced  move- 
ments of  the  joint  and  throw  excessive  strain  on  the  ligaments.  The  stability  of  the  joint 
depends  further  on  the  density  of  the  surrounding  fascia  with  its  abundant  muscular  inser- 
tions, the  numerous  surrounding  tendons,  the  strength  and  number  of  the  ligaments,  espe- 
cially the  crucial,  and  the  special  arrangement  of  the  interarticular  cartilages,  by  which  a 
contact  of  the  bony  surfaces,  as  exact  and  extensive  as  possible,  is  ensured  in  all 
positions,  in  spite  of  the  variations  in  the  curve  of  the  condyles  of  the  femur.  The 
substitution  of  muscular  expansion  for  a  strong  capsule  on  the  aspect  of  the  joint  most 
affected  by  its  movements  finds  here  its  most  striking  example  in  the  arrangement  of  the 
quadriceps  tendon  ;  while  in  the  oblique  fasciculus  of  the  posterior  ligament  we  have  an 
excellent  example  of  the  strengthening  and  modification  in  character  of  a  ligament  by  the 
addition  of  a  tendinous  insertion — that  of  the  semimembranosus.  The  importance  of  the 
latter  arrangements  to  the  stability  of  an  articulation,  such  as  the  knee,  is  evident,  since,  if 
taken  by  surprise,  the  strain  is  not  thrown  against  an  inelastic  band  of  white  fibrous  tissue, 
like  a  pure  ligament,  but  against  a  structure  which  is  to  some  extent  under  a  muscular  or 
contractile  control  capable  of  breaking  and  modifying  a  sudden  shock. 

Frequency  of  Occurrence. — Dislocations  of  the  tibia  are  rare.  In 
1207  dislocations  seen  at  St. Thomas's  Hospital,  3  examples  occurred,  or 
O.24  per  cent.  In  Kronlein's  statistics,  4  occurred  in  a  total  of  400 
dislocations,  or  1  per  cent.     Not  one  of  the  whole  7  was  complete. 

Causation  and  Classification. — The  sagittal  dislocations  generally, 
and  the  lateral  always,  are  the  result  of  indirect  violence,  and  are  caused 
by  falls  on  the  feet  followed  by  an  excessive  movement  of  the  knee, 
due  to  the  further  progress  of  the  body.  Forward  displacement 
usually  results  from  hyperextension,  such  as  may  be  caused  by  falling 
forward  of  the  body  when  the  foot  and  leg  are  fixed  in  a  hole.  The 
condyles  of  the  femur  reach  the  anterior  border  of  the  tibia,  and  are 
thrown  against  the  posterior  part  of  the  capsule ;  this  and  the  posterior 
part  or  whole  of  the  lateral  ligaments  are  ruptured  by  the  condyles,  and 
a  dislocation  occurs.  In  the  lateral  dislocations  a  movement  of  abduc- 
tion or  adduction  of  the  knee  in  the  same  way  throws  the  femur  against 
the  opposite  lateral  ligament,  which  is  ruptured,  and  allows  a  dislocation 
to  be  produced  in  the  opposite  direction.  The  sagittal  displacements  may 
also  be  produced  by  direct  violence ;  thus,  an  anterior  dislocation  may 
result  from  the  falling  of  a  heavy  body  on  the  front  of  the  thigh  with 
a  flexed  knee,  the  femur  being  driven  backward ;  or  a  posterior  dislo- 


SPECIAL    DISLOCATIONS. 


647 


cation  may  result  from  a  blow  received  by  the  anterior  aspect  of  the 
tibia  with  a  slightly  or  fully  flexed  knee.  A  case  of  lateral  dislocation 
from  violence  exerted  on  the  side  of  the  thigh  with  a  fixed  leg  has 
also  been  recorded. 

Pathology. — A  large  proportion  of  the  forward  dislocations  are  incomplete,  a  still 
larger  of  the  posterior,  while  the  lateral  are  nearly  always  incomplete. 

Symptoms. — In  forward  dislocation  the  knee  is  usually  extended 
or  hyperextended,  the  latter  position  causing  a  posterior  inflexion. 
The  tubercle  of  the  tibia  is  very  prominent.  From  it  the  tense  liga- 
mentum  patellae  slopes  backward,  with  a  hollow  on  either  side,  and 
above  this  the  patella  itself  is  seen  bounding  a  considerable  hollow 
over  the  lower  end  of  the  femur.  The  popliteal  hollow  is  obliterated, 
and  the  anteroposterior  diameter  is  considerably  increased.  In  com- 
plete dislocation  shortening  of  from  1  to  4  inches  has  been  observed. 
On  palpation  the  anterior  margin  of  the  head  of  the  tibia  is  felt  on 
either  side  of  the  ligamentum  patellae,  and  in  complete  dislocations  the 
outline  of  the  facets  on  its  upper  surface  can  be  made  out.  The  patella 
itself  lies  in  a  more  or  less  sloping  position  over  the  upper  end  of  the 
tibia.  The  expansion  of  the  quadriceps  is  loose  and  in  folds  which 
obscure  the  upper  margin  of  the  patella.  Posteriorly  the  condyles  are 
readily  felt,  and,  when  the  gastrocnemius  is  much  lacerated,  may  be 
actually  subcutaneous.  On  manipulation  little  movement  is  possible, 
unless  the  ligamentous  laceration  is  unusually  free,  and  then  the  leg 
simply  hangs  loosely.  The  ves- 
sels in  the  popliteal  space  may 
be  compressed,  and  there  may 
be  great  pain  from  pressure  on 
the  popliteal  nerves. 

In  backward  dislocation  the 
limb  is  usually  extended  or 
hyperextended.  The  same  in- 
crease in  the  anteroposterior 
diameter  is  observed  as  in  the 
forward  variety,  and  if  the  dislo- 
cation is  complete  there  is  short- 
ening of  the  leg.  Anterior!}'  a 
prominence  is  seen  above  the 
level  of  the  joint-cleft,  consisting 
of  the  condyles  of  the  femur; 
posteriorly,  one  due  to  the  dis- 
placed head  of  the  tibia,  which 
may  be  above  or  below  the  level 
of  the  joint-cleft,  according  as 
the  displacement  is  complete  or 
not.  Hollows  exist  below  and 
above    these    prominences,    and 

the  outline  of  the  ligamentum  patellae  may  be  observed  crossing  the 
anterior  one. 

On  palpation  the  outline  of  all  the  upper  part  of  the  trochlea  may 
be  mapped  out  on  the  prominent  condyles,  while  on  either  side  of  the 
ligamentum  patellae  the   under  surface  of  the  condyles  may  be  felt. 


FlG.  315. —  Backward  dislocation  of  the  tibia. 


648  INTERNATIONAL    TEXT-BOOK  OF  SURGERY 

In  complete  dislocation  the  patella  itself  is  horizontally  applied  to  the 
under  aspect  of  the  condyles  in  their  center.  The  prominent  margin 
of  the  head  of  the  tibia  may  be  felt  posteriorly.  On  manipulation 
little  movement  is  possible,  and  this  only  in  the  direction  of  flexion, 
together  with  some  abnormal  lateral  mobility. 

Lateral  dislocations  are  seldom  complete,  and  as  the  movement  of 
forced  abduction  is  so  much  more  frequent  than  that  of  adduction,  dis- 
placement outward  is  the  commoner  variety. 

On  inspection  the  limb  is  usually  found  extended,  the  foot  rotated 
out  in  the  outward  variety,  and  the  reverse  when  the  displacement  is 
inward.  The  lateral  diameter  of  the  limb  is  increased.  A  prominence 
exists  on  either  side,  that  above  the  level  of  the  joint-cleft  correspond- 
ing with  a  femoral  condyle,  the  skin-covering  of  which  is  usually  tense 
and  shining,  and  that  below  corresponding  with  a  tibial  tuberosity. 
On  palpation  the  outline  of  the  condyle  and  tuberosity  respectively 
can  be  mapped  out,  and  the  trochlear  surface  of  the  femur  is  also  trace- 
able, since  the  patella  is  carried  with  the  tibia  over  the  margin  of  the 
condyle. 

Prognosis. — Immediate  reduction  is  seldom  difficult ;  indeed,  the 
bystanders  after  one  of  these  accidents  have  not  unfrequently  reduced 
the  dislocation  by  pulling  the  leg.  The  prognostic  importance  depends 
on  the  extensive  ligamentous  rupture,  which  leaves  permanent  weak- 
ness, and  may  be  followed  by  deformity,  such  as  bowed  leg  or  knock- 
knee.  In  simple  cases  the  most  serious  complications  are  dependent 
on  injury  to  the  vessels.  Gangrene  has  been  seen  to  occur,  either 
within  the  first  few  days  or  as  late  as  the  fourth  week.  In  this  respect 
backward  dislocations  have  proved  themselves  more  dangerous  than 
forward  ones,  since  the  artery  has  not  the  advantage  of  the  protection 
offered  by  the  popliteal  notch  of  the  femur. 

Treatment. — The  simplest  method  of  reduction  is  the  best,  and  is 
generally  applicable.  Traction  is  made  in  the  axis  of  the  displaced 
bone,  while  direct  pressure  is  made  on  the  two  articular  extremities 
in  the  required  direction — i.  c,  backward  or  forward  for  the  femur,  and 
downward  for  the  tibia.  If  this  fail,  traction  followed  by  flexion  may 
be  tried  in  the  forward  and  backward  varieties.  If  necessary,  the  fore- 
arm of  an  assistant  may  be  placed  in  the  popliteal  space,  both  to  pro- 
duce some  extension  and  to  act  as  a  fulcrum.  In  the  lateral  varieties 
a  combination  of  abduction  or  adduction,  whichever  has  led  to  the 
original  injury,  will  be  best  combined  with  traction. 

After-care  needs  to  be  very  prolonged.  A  fixed  support,  such  as  a 
plaster-of-Paris  splint,  must  be  constantly  worn  for  at  least  six  weeks, 
and  should  be  removed  only  for  the  application  of  massage  to  the 
muscles  above  and  below  the  joint.  Gentle  passive  movement  may 
then  be  made,  and  as  strength  increases,  active  exercises  should  be 
cautiously  commenced.  A  hinged  lateral  support  should  be  worn  for 
at  least  a  year,  and  it  may  be  advisable  to  retain  it  still  'longer  if  there 
is  any  appreciable  lateral  weakness.  Compound  dislocations  are  very 
rare,  and  must  be  treated  on  general  principles.  Commonly  the  only 
substitute  for  conservative  treatment  is  amputation. 

Congenital  dislocation  is  occasionally  met  with,  and  may  be  sym- 
metrical. 


SPECIAL   DISLOCATIONS.  649 

Isolated  Dislocation  of  the  Fibula. — This  accident  is  a  rare 
one.  The  upper  end  of  the  bone  is  occasionally  displaced  by  direct 
violence  or  by  forcible  contraction  of  the  biceps.  It  may  also  com- 
plicate a  fracture  of  the  upper  third  of  the  tibia.  A  case  is  on  record 
in  which  both  ends  were  separated,  dislocation  first  occurring  at  the 
ankle,  and  the  bone  being  then  driven  bodily  upward. 

Symptoms. — Displacement  of  .the  upper  end  is  readily  recognized 
by  palpation  of  the  head,  which  is  situated  either  too  far  forward  or 
backward,  and  in  one  recorded  case  was  upward.  The  outer  surface 
of  the  leg  is  flattened,  a  depression  takes  the  place  of  the  normal 
prominence  of  the  head,  the  biceps  tendon  is  tense,  and  power  of 
extension  of  the  leg  is  more  or  less  impaired. 

Treatment. — The  head  should  be  reduced  by  direct  pressure,  and 
the  limb  slightly  flexed  and  put  up  in  plaster  of  Paris.  The  small 
area  of  the  joint-surfaces  and  the  pull  of  the  biceps  are  unfavorable  to 
a  good  result.  Small  inconvenience,  however,  seems  to  have  resulted, 
but  the  obvious  treatment  is  to  fix  the  head  of  the  bone  to  the  tibia, 
either  by  a  screw  or  a  suture. 

Patella. — The  position  of  the  patella  is  maintained  by  the  various 
parts  of  the  quadriceps  extensor  cruris,  any  vertical  movement  being 
necessarily  controlled  by  the  attachment  of  the  ligament  to  the  tibia. 
Lateral  shifting,  however,  is  possible  in  the  groove  of  the  femoral 
trochlea,  especially  in  the  extended  position. 

The  obliquity  of  the  thigh  necessitates  a  corresponding  slope  in  the  inward  direction  of 
the  quadriceps,  which  is,  however,  to  a  small  degree  reversed  in  the  ligamentum  patellae. 
Hence,  in  the  normal  state  the  patella  forms  the  apex  of  a  triangle,  salient  inward.  To 
neutralize  the  consequent  tendency  to  outward  displacement  of  the  knee-cap  when  the  mus- 
cle contracts,  we  find  that  the  vastus  interims  has  a  much  more  extensive  muscular  insertion 
into  the  inner  patellar  margin  than  the  vastus  externus  has  to  the  outer.  In  spite  of  this 
arrangement,  the  comparative  frequency  of  outward  displacements  and  the  rarity  of  inward 
ones  conclusively  demonstrate  the  influence  of  the  anatomical  arrangement.  In  the  posi- 
tion of  flexion  the  patella  sinks  deeply  into  the  intercondylar  notch  overlying  the  cleft  of 
the  knee-joint,  and  lateral  displacement  is  opposed  by  the  tension  of  the  quadriceps.  In 
extension,  on  the  other  hand,  the  patella  is  prominent,  rests  on  the  trochlea  by  its  lower 
part  only,  and  the  quadriceps  is  not  stretched  ;  hence,  extension  is  the  position  of  danger 
for  the  patella. 

Frequency  of  Occurrence. — In  the  1207  dislocations  seen  at  St. 
Thomas's  Hospital,  4  were  of  the  patella,  or  a  ratio  of  .33  per  cent. 
Kronlein  saw  3  in  400  dislocations,  or  .75  per  cent. 

Causation  and  Classification. — Dislocations  of  the  patella  are 
usually  the  result  of  sudden  contraction  of  the  quadriceps,  and  there- 
fore they  are  due  to  muscular  action  ;  but  they  may  be  caused  by 
direct  violence  in  blows  or  falls,  the  margin  of  the  bone  being  the  point 
of  impact. 

The  bone  is  commonly  dislocated  outward  ;  very  rarely  in  the  oppo- 
site direction.  Dislocation  outward  relaxes  the  quadriceps,  inward  tight- 
ens it — another  reason  for  the  rarity  of  the  inward  variety.  Dislocation 
upward  results  only  from  rupture  of  the  ligamentum  patellae  (Fig.  316). 
Beyond  these  forms,  a  rotatory  displacement,  in  which  either  the  inner 
or  outer  margin  of  the  bone  rests  in  the  notch  between  the  condyles, 
occurs  ;  and  this  may  be  complete,  the  articular  surface  looking  for- 
ward. 

Luxation    outward    in    cases    of    knock-knee   is    by   no    means    a 


650 


J.\  I ERNATIONAL    TEXT-BOOK  OF  SURGERY. 


rare  spontaneous  occurrence,  and  hence  a  degree  of  genu  valgum 
only  slightly  emphasizing  the  normal  physiological  arrangement  must 
be  looked  upon  as  predisposing  to  the  occurrence,  and  no  doubt 
does  explain  some  cases  of  outward  displacement.  In  congenital  dis- 
placements of  this  bone,  genu  valgum  results,  and  it  has  also  been 
observed  to  develop  as  a  result  of  unreduced  traumatic  dislocations. 

Pathology. — A  slit  is  produced  in  the  side  of  the  capsule  opposite  that  of  the  dis- 
placement. Vertical  displacement  makes  a  double  slit  necessary.  Tension  of  the  remaining 
bands  is  usually  regarded  as  the  cause  of  the  fixation  of  the  bone  in  false  position. 

Symptoms. — In  lateral  dislocations,  when  displacement  is  complete, 
the  knee  is  about  one-quarter  flexed ;  in  incomplete  dislocations  it  is 

sometimes  extended.  The  front 
of  the  knee  is  widened,  the  nor- 
mal prominence  of  the  patella  is 
shifted  to  one  or  the  other  side, 
and  a  hollow  exists  in  its  position 
over  the  center  of  the  femur, 
bounded  by  the  prominent  mar- 
gin of  the  displaced  patella.  On 
palpation  the  position  of  the  pa- 
tella may  be  determined,  while 
either  the  whole  or  part  of  the 
outline  of  the  trochlea  may  be 
traced,  in  addition  to  the  abnor- 
mally coursing  ligamentum  pa- 
tellae. On  manipulation  little 
movement  is  possible,  and  that 
very  painful. 

In  rotatory  dislocation,  the 
knee  is  extended,  a  central  prom- 
inence formed  by  the  margin  of 
the  patella  increases  the  sagittal 
diameter  of  the  limb,  and  on 
either  side  of  this  is  a  hollow. 
On  palpation  the  position  of  the 
patella  and  the  direction  of  its 
cartilaginous  surface  are  readily  determined.  The  quadriceps  is  very 
tense.  Complete  rotation  is  seen  both  as  a  result  of  muscular  action 
or  complete  violence. 

Prognosis. — The  function  of  the  limb  becomes  fair,  even  if  the  dis- 
placement is  unreduced  ;  but  both  flexion  and  complete  extension  are 
somewhat  interfered  with. 

Treatment. — To  reduce  the  displacements,  the  hip  must  be  flexed 
and  the  knee  extended,  while  direct  pressure  is  made  upon  the  patella. 
If  this  fails,  forcible  flexion,  followed  by  extension,  may  be  tried.  In 
suitable  individuals,  where  these  methods  are  unsuccessful,  an  open  inci- 
sion may  be  made,  and  after  division  of  the  tense  bands  of  the  capsule, 
the  patella  may  be  temporarily  fixed  in  position  with  a  peg  or  screw. 
Cases  of  rotatory  displacement,  however,  are  on  record  where  even  the 
open  method  has  failed. 


FlG.  316. —  Rupture  of  the  ligamentum 
patellae;  upward  displacement  of  the  bone 
(St.  Thomas's  Museum,   London). 


SPECIAL   DISLOCATIONS.  65  I 

Foot. — The  ankle  forms  one  of  the  purest  examples  of  the  hinge- 
joint,  lateral  movement  being  opposed  by  strong  radiating  ligaments, 
and  large  bony  processes  extending  over  the  entire  lateral  aspects. 
Under  these  circumstances  it  will  be  readily  understood  that  lateral  dis- 
placements do  not  occur  without  fractures  of  the  bones ;  thus,  a  partial 
outward  displacement  is  always  treated  of  as  Pott's  fracture,  and  a  more 
complete  one  as  Dupuytren's,  while  inward  displacements  are  accom- 
panied by  fracture  of  the  internal  malleolus.  These  will  therefore 
meet  with  no  further  mention  here.  An  upward  displacement  is  often 
described,  the  dislocation  being  not  of  the  astragalus  alone,  but  com- 
bined with  a  diastasis  of  the  inferior  tibiofibular  articulation.  Although 
there  is  some  doubt  as  to  whether  this  separation  is  not  actually  due,  in 
most  cases,  to  an  oblique  fracture  of  the  tibia,  it  demands  brief  notice 
here.  It  has  been  caused  by  falls  on  the  foot  in  a  horizontal  position. 
The  signs  consist  in  a  widening  of  the  transverse  diameter  of  the  ankle, 
approximation  of  the  malleoli  to  the  margin  of  the  sole,  and  extreme 
fixity  of  the  foot.  Reduction  has  proved  extremely  difficult  or  impos- 
sible. 

Sagittal  Dislocations. — Pure  forward  and  backward  dislocations  of 
the  foot  occur  rarely. 

Frequency  of  Occurrence. — In  1207  dislocations  observed  at  St. 
Thomas's  Hospital,  3  of  the  ankle  occurred,  or  .24  per  cent.  In 
Kronlein's  statistics,  2  occurred  in  400,  or  .5   per  cent. 

Causation. — The  majority  of  observed  instances  have  been  the  result 
of  indirect  violence,  the  tibia,  strictly  speaking,  being  the  bone  dislocated. 
Thus,  the  backward  and  more  common  variety  has  been  caused  by  falls 
on  the  feet,  the  body  falling  forward ;  or  the  knee  and  ankle  are  flexed 
to  a  degree  in  which  the  tibia  bursts  the  posterior  ligament  and  passes 
on  to  the  upper  surface  of  the  os  calcis  in  its  non-articular  portion. 
Again,  the  tibia  has  been  driven  backward  by  a  blow  upon  the  flexed 
knee  while  the  person  was  in  a  squatting  position.  Thus,  the  displace- 
ment is  the  result  of  hyperflexion.  Forward  dislocation  is  the  result 
of  the  opposite  movement  of  hyperextension.  In  this  case  again,  falls 
on  the  feet  are  the  commonest  cause.  The  foot  becomes  the  fixed 
point,  and  the  body  falling  backward,  the  tibia  finds  an  abnormal  ful- 
crum in  the  posterior  margin  of  the  astragalus,  and  bursts  the  capsule 
anteriorly.  The  leg  has  been  known  to  form  the  fixed  point,  and  the 
foot  has  been  driven  forward  by  direct  violence  applied  to  the  heel. 

Pathology. — Complete  dislocation  in  either  direction  necessitates  rupture  of  both  lateral 
ligaments.  These  are  very  strong,  so  that  in  the  lateral  displacements  fracture  is  common  ; 
thus,  the  internal  malleolus  has  been  found  fractured  in  the  forward  variety,  and  the  external 
in  the  backward.  Either  dislocation  may  be  complete  or  incomplete.  In  the  complete  for- 
ward, the  tibia  rests  on  the  posterior  part  of  the  os  calcis  ;  in  the  complete  backward,  on  the 
fore  part  of  the  astragalus  and  scaphoid.  In  the  incomplete  varieties  the  tibia  rests  on  some 
part  of  the  articular  trochlea  of  the  astragalus  by  its  anterior  or  posterior  margin.  Either 
variety,  when  complete,  causes  great  tension  of  the  skin,  which  may  be  burst  or  give  way 
secondarily  as  the  result  of  the  injury  it  has  suffered. 

Symptoms. — In  dislocation  backward  the  foot  is  extended,  and  if  the 
external  malleolus  is  broken,  somewhat  abducted.  The  dorsum  of  the 
foot  is  shortened.  The  rounded  lower  end  of  the  tibia  is  prominent, 
and  below  it  a  marked  groove  or  crease  of  the  skin  corresponds  with 
the  cleft  of  the  ankle-joint.     The  heel  projects  strongly,  and  the  dis- 


652  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

tance  between  it  and  the  malleolus  is  increased.  The  tendo  Achillis  is 
prominent,  and  forms  a  sharp  curve,  concave  backward ;  a  deep  hollow 
exists  on  either  side  of  it.  On  palpation  the  relation  of  the  bony  parts 
can  be  confirmed,  and  possibly  the  astragalus  felt  in  its  new  position 
from  one  or  the  other  side  of  the  tendon.  On  manipulation  little 
movement  is  possible,  and  attempts  at  it  are  very  painful. 

In  dislocations  forward  the  foot  is  moderately  extended,  the  dorsum 
elongated,  the  heel  deficient  in  prominence.  The  tips  of  the  malleoli 
are  approximated  to  the  sole ;  the  tendo  Achillis  falls  vertically.  On 
palpation  the  malleoli  can  be  felt  on  either  side,  in  very  close  proximity 
to  the  tendo  Achillis  ;  and  the  upper  surface  of  the  astragalus  can  be 
traced  anteriorly.  If  the  displacement  is  incomplete  in  either  direction, 
the  signs  are  similar,  but  less  strongly  marked. 

Diagnosis. — The  main  point  in  the  diagnosis  of  these  injuries  is  the 
alteration  of  the  relation  of  the  malleoli  to  the  bones  of  the  tarsus. 
Determination  of  this,  taken  with  the  alterations  in  the  appearance 
already  described,  will  obviate  any  source  of  error. 

Prognosis. — Beyond  a  slightly  marked  tendency  to  recurrence,  these 
dislocations  offer  little  difficulty.  If  unreduced,  the  function  of  the 
foot  is  much  interfered  with. 

Treatment. — The  knee  is  flexed  to  relax  the  tendo  Achillis,  and 
traction  made  on  the  foot,  combined  with  flexion  or  extension  in  the 
forward  and  backward  dislocations  respectively.  The  foot  should  then 
be  fixed  in  a  plaster-of-Paris  splint.  The  date  for  the  commencement 
of  passive  movement  will  vary  with  the  amount  of  the  original  dis- 
placement and  the  consequent  degree  of  rupture  of  the  lateral  liga- 
ments. In  any  case  a  three  weeks'  interval  is  necessary,  and  an 
apparatus  is  needful  for  some  months.  Reduction  has  been  facilitated 
in  difficult  cases  by  tenotomy  of  the  tendo  Achillis.  In  unreduced 
dislocations,  excision  should  be  limited,  if  possible,  to  the  astragalus, 
and  consist  in  either  partial  or  complete  removal  of  that  bone.  The 
question  of  lateral  arthrotomy  with  osteoplastic  resection  of  one  of 
the  malleoli  may  also  be  considered  as  a  substitute. 

The  skin  in  these  dislocations  is  not  infrequently  much  contused, 
and  not  rarely  lacerated.  Great  care  must  be  exercised  in  the  appli- 
cation of  apparatus  when  the  contusion  is  severe,  and  also  caution  in 
the  application  of  cold.  Compound  dislocation  must  be  treated  on 
ordinary  lines  ;  but  it  may  be  remarked  that  if  the  wound  is  other  than 
a  puncture  from  a  fractured  malleolus,  the  condition  of  the  soft  parts  is 
usually  unsuitable  for  an  excision,  either  partial  or  complete. 

Subastragaloid  Dislocations. — The  movements  of  abduction  and 
adduction  of  the  foot  on  the  leg,  or  the  leg  on  the  foot,  when  the  latter 
is  the  fixed  point,  take  place  in  the  astragalocalcanean  joint,  around  an 
oblique  axis  corresponding  with  the  attachment  of  the  powerful  inter- 
osseous ligament. 

The  circumference  of  the  joint  is  closed  by  a  capsular  ligament  of  varying  consistence, 
but  strengthened  by  the  continuation  of  the  internal  lateral  ligament  of  the  ankle  to  the 
sustentaculum  tali,  and  of  the  middle  fasciculus  of  the  external  lateral  ligament  to  the  tuber- 
cle on  the  outer  surface  of  the  os  calcis.  Limitation  of  movement  in  the  articulation  is  due 
to  bony  contact ;  thus,  of  the  posterior  and  inner  part  of  the  astragalus  with  the  posterior 
part  of  the  calcaneum  in  adduction,  and  the  head  of  the  astragalus  with  the  fore  and  outer 
part  of  the  greater  process  of  the  os  calcis  in  abduction.      In  a  too  free  movement  in  either 


SPECIAL   DISLOCATIONS.  653 

direction,  such  as  occurs  in  alighting  violently  on  the  foot,  the  body  falling  to  one  side  or 
the  other,  a  false  fulcrum  is  established  by  bony  contact,  and  sufficient  force  is  exerted  on 
the  interosseous  ligament  to  tear  it  from  its  attachments.  The  head  of  the  astragalus  then 
bursts  its  connections  with  the  scaphoid,  and  a  displacement  of  the  remaining  bones  of  the 
tarsus  from  the  astragalus  and  the  bones  of  the  leg  takes  place,  either  in  an  inward  or  out- 
ward direction.  Lateral  oblique  displacements  caused  in  this  way  are  the  most  common  ; 
but  very  rarely,  probably  as  a  result  of  a  flexed  or  extended  position  of  the  foot,  or  of  direct 
violence,  a  more  or  less  anterior  or  posterior  one  may  take  place. 

Frequency  of  Occurrence. — In  1207  dislocations  observed  at  St. 
Thomas's  Hospital,  6  subastragaloid  occurred,  a  ratio  of  .49  per  cent. 
All  were  of  the  oblique  inward  variety.  In  Kronlein's  statistics  no 
instance  was  noted. 

Causation. — Violent  adduction  or  abduction  due  to  falls  on  the  feet, 
the  latter  being  firmly  planted  on  the  ground,  or  more  rarely  actually 
fixed  mechanically.  With  a  fixed  foot,  violence  applied  laterally  to 
the  leg  may  act  in  a  similar  manner. 

Symptoms. — In  inward  dislocation  the  foot  is  adducted  and  rotated 
inward  in  its  fore  part.  The  inner  border  is  raised  and  concave.  The 
head  of  the  astragalus  forms  a  prominent  swelling  on  the  outer  part 
of  the  dorsum,  while  the  external  malleolus  is  prominent,  and  beneath 
it  is  a  hollow  corresponding  to  the  usual  position  of  the  os  calcis. 
The  internal  malleolus  is  obscured,  while  below  it  the  sustentaculum 
tali  is  prominent,  and  also  the  lower  inner  margin  of  the  os  calcis 
(Fig.  317).  On  palpation  these  points  can  be  confirmed,  and  the 
articular  cavity  of  the  scaphoid  may  be  traced.  On  manipulation  the 
movements  of  flexion   and  extension  are  allowed  to  a  limited  degree ; 


FlG.  317. — Inward  subastragaloid  dislocation  (St.  Thomas's  Museum,  London). 

adduction   also  may  be  increased,  but   abduction   is   impossible.     All 
movement  is  very  painful. 

In  outward  dislocation  the  foot  is  abducted,  the  fore  part  externally 
rotated ;  but  the  outer  border  does  not  leave  the  ground,  so  that  an 
appearance  of  flat  foot    is  assumed.     The  internal  malleolus  is  very 


654  INTERNATIONAL    TEXT-BOOK   OF  SCR G TRY. 

prominent  and  the  skin  tense  over  it.  Anteriorly  the  head  of  the 
astragalus  is  prominent.  On  palpation  the  above  points  can  be  con- 
firmed, the  scaphoid  may  be  felt  on  the  dorsum,  and  along  the  outer 
border  the  margins  of  the  cuboid  and  os  calcis,  and  a  hollow  corre- 
sponding to  the  proper  position  of  the  astragalar  head.  On  manipu- 
lation adduction  is  impossible,  but  some  flexion  and  extension  can  be 
made  ;  and  in  the  anterior  section  of  the  foot  there  may  be  some 
abnormal   mobility. 

The  forward  and  backward  displacements  are  very  rare,  and  prob- 
ably result  from  violence  of  the  same  nature  as  that  producing  the 
corresponding  dislocations  of  the  ankle. 

In  the  backward  dislocation  the  foot  is  shortened  and  the  head  of 
the  astragalus  rests  on  the  dorsum  of  the  scaphoid;  the  heel  is  elon- 
gated and  the  tendo  Achillis  prominent.  Some  flexion  and  extension 
are  allowed  at  the  ankle-joint,  but  little  lateral  movement. 

In  the  forward  displacement  the  foot  is  lengthened  and  the  prom- 
inence of  the  heel  abolished ;  movements  of  flexion  and  extension  at 
the  ankle  are  possible. 

Subastragaloid  dislocations  are  often  compound,  and  frequently 
complicated  by  fracture  of  the  neck  of  the  astragalus  and  of  the 
malleoli,  or  the  tearing  off  of  small  fragments  of  bone  with  the 
detached  ligaments. 

Diagnosis. — Discrimination  of  the  different  varieties  depends  on 
careful  determination  of  the  points  above  detailed ;  but  it  may  be 
repeated  that  the  special  characteristic  of  subastragaloid  dislocations, 
as  compared  with  those  of  the  ankle,  is  the  retention  of  the  proper 
relation  of  the  astragalus  to  the  malleoli,  and  the  possibility  of  passive 
movements  of  flexion  and  extension,  while  adduction  and  abduction 
are  interfered  with. 

Prognosis. — Most  of  these  dislocations  are  reduced  fairly  easily  in 
the  recent  state.  If  left  unreduced,  a  very  unsatisfactory  foot  results. 
In  compound  dislocation  the  prognosis  is  usually  not  very  favorable, 
on  account  of  the  contusion  and  laceration  and  the  difficulty  of  pro- 
ducing and  maintaining  asepticity. 

Treatment. — Reduction  is  best  effected  by  inducing  anesthesia  and 
then  flexing  the  leg  on  the  thigh,  the  thigh  being  held  by  an  assistant, 
who  makes  counterextension,  while  the  surgeon  makes  traction  on  the 
displaced  foot  and  endeavors  to  manipulate  it  into  position.  Tenotomy 
of  the  tendo  Achillis  may  be  necessary.  When  reduced,  the  foot  must 
be  put  up  in  plaster  of  Paris  and  be  kept  at  rest  for  at  least  six  weeks. 
If  reduction  proves  impossible,  the  foot  should  be  kept  at  rest  for  a 
few  days  to  allow  of  settling  down  of  the  damaged  structures,  and  the 
astragalus  may  then  be  partially  or  wholly  removed. 

In  this,  as  in  most  compound  dislocations  of  the  foot,  the  use  of 
antiseptic  baths  cannot  be  too  highly  recommended ;  and  as  a  pre- 
liminary to  this  treatment  it  is  well  to  suture  the  displaced  bones 
together,  so  as  to  be  more  or  less  free  as  to  splints  in  the  movements 
necessary  to  the  periodic  removal  of  the  foot  from  the  bath.  The  need 
for  care  in  ensuring  that  no  injurious  pressure  shall  be  made  on  the 
leg,  and  in  not  allowing  the  tissues  to  become  sodden  by  a  too  long 
stay  in  the  bath,  need  only  be  mentioned. 


SPECIAL   DISLOCATIONS.  655 

Dislocations  of  the  Astragalus. — The  sheltered  position  of  the 
astragalus  makes  it  strange  that  it  should  be  the  bone  of  the  tarsus 
most  commonly  dislocated.  This  accident  is  said  to  occur  more  fre- 
quently than  even  subastragaloid  dislocation.  The  explanation  is  no 
doubt  found  in  the  fact  that  the  bone  receives  directly  the  whole  trans- 
mitted weight  of  the  trunk,  to  disperse  it  forward  and  backward  to  the 
remainder  of  the  tarsus. 

Frequency  of  Occurrence. — In  1207  dislocations  of  all  joints  at  St. 
Thomas's  Hospital,  3  of  the  astragalus  were  observed,  or  .24  per  cent. 
No  instance  occurs  in  Kronlein's  series. 

Causation  and  Classification. — The  actual  mode  of  causation  of 
these  dislocations  is  far  from  clear.  It  would  naturally  be  expected 
that  the  violence  producing  them  would  correspond  with  that  produc- 
ing the  sagittal  dislocations  of  the  whole  tarsus  at  the  ankle — that  is, 
hyperextension  in  backward,  hyperflexion  in  forward,  displacements. 
Recorded  histories,  however,  do  not  altogether  support  this  theory, 
since,  for  instance,  forward  dislocation  has  been  observed  to  occur 
with  a  history  of  either  extension  or  flexion.  This  may  depend  in 
part  on  the  fact  that  exact  histories  of  an  accident  caused  by  sudden 
and  great  violence  are  seldom  altogether  reliable,  but  more  probably 
on  the  nature  of  the  violence  exerted,  which  is  seldom  simple  in  direc- 
tion, but  often  combined  with  severe  twisting  and  wrenching-. 

The  bone  may  be  displaced  either  backward  or  forward ;  but  in 
either  case  a  lateral  direction  is  assumed,  usually  combined  with  some 
rotation.  Thus,  we  have  forward  and  inward,  forward  and  outward, 
backward  and  inward,  and  backward  and  outward  varieties.  The  lat- 
eral deviation  is  determined  by  the  position  of  the  foot  at  the  moment 
of  injury;  if  abducted,  the  inclination  of  the  astragalus  is  inward;  if 
adducted,  outward.  Displacement  may  be  complete  or  incomplete,  and 
is  often  complicated  by  fracture  of  the  neck  of  the  bone. 

The  most  striking  variety  is  the  pure  rotatory.  Here  the  astrag- 
alus is  rotated  so  as  to  lie  on  one  side  or  the  other ;  or  it  ma)*  even  be 
completely  reversed,  so  that  the  under  surface  is  directed  toward  the 
tibia.  It  may  take  a  horizontal  position  across  the  front  of  the  mal- 
leolar arch.  These  versions  probably  depend  on  the  fact  that  the 
primary  injury  is  a  severe  wrench  or  twist,  in  which  the  astragalus 
first  loses  its  connection  to  the  bones  of  the  leg  and  accompanies  the 
rest  of  the  tarsus,  from  which  it  is  then  separated  by  the  final  pressure 
of  the  weight  of  the  body.  On  the  cessation  of  the  violence,  the 
tendency  of  the  foot  is  to  resume  its  normal  position.  The  remaining 
bones  of  the  foot  readily  do  this,  the  hollow  upper  surface  of  the  os 
calcis  turning  on  the  displaced  and  free  astragalus.  The  somewhat 
angular  astragalus,  however,  cannot  so  readily  turn  in  its  confined 
space,  and  hence  remains  rotated ;  or  the  rotation  may  be  increased  or 
completed  by  the  passage  of  the  os  calcis  to  the  median  line  beneath 
it.  Again,  supposing  a  twist  severe  enough  to  bring  the  astragalus 
forward  out  of  the  tibiofibular  arch,  and  then  the  weight  of  the  body 
to  complete  its  separation,  as  the  violence  is  relinquished,  the  foot 
tends  to  resume  its  position,  while  the  astragalus  probably  hitches 
against  one  of  the  malleoli,  and  thus  its  transverse  direction  is  made 
more  pronounced  and  permanent. 


656  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

Pure  lateral  displacements  have  been  described,  but  always  in  cases 
of  a  compound  nature,  and  usually  in  combination  with  fracture  of  a 
malleolus.  When  the  interosseous  ligament  is  completely  torn  from 
the  astragalus,  the  main  nutrient  vessels  which  enter  by  the  floor  of 
the  groove  arc  all  torn  ;  hence  the  frequent  occurrence  of  necrosis. 

Symptoms. — In  forward  displacement  the  astragalus  forms  a  marked 
projection  on  the  dorsum  of  the  foot,  either  to  the  inner  or  outer  side, 
according  to  the  lateral  direction  which  it  has  taken.  The  prominence 
resembles  in  outline  the  head  of  the  astragalus,  and  the  skin  is  tense 
and  shining  over  it.  The  malleoli  are  approximated  to  the  margin  of 
the  sole.  The  foot  is  deflected  to  the  opposite  direction  to  that  taken 
by  the  head ;  the  corresponding  malleolus  is  prominent,  the  other 
sunken.  On  palpation  the  trochlea,  or  part  of  it,  can  be  felt,  as  well 
as  the  outline  of  the  head.     If  the  dislocation  is  complete,  the  head 


Fig.  318. —  Forward  and  outward  dislocation  of  the  astragalus  (St.  Thomas's 
Museum,  London). 

rests  on  the  cuneiform  bones ;  if  incomplete,  on  either  the  inner  or 
outer  part  of  the  dorsum  of  the  scaphoid,  the  posterior  extremity  of 
the  bone  still  lying  beneath  the  malleolar  arch.  On  manipulation  all 
movement  of  flexion  and  extension  at  the  ankle  is  impossible  (Figs. 
3i8,  319). 

In  backward  displacement  the  foot  is  extended,  the  distance  between 
the  malleoli  and  the  sole  is  diminished,  and  a  projection  may  be  present, 
pushing  the  tendo  Achillis  backward,  or  situated  on  one  side  of  it  or 
the  other,  according  to  the  direction  taken  by  the  astragalus.  In  the 
oblique  lateral  displacements  the  skin  may  be  very  tightly  stretched 
over  this.  The  tibia  is  thrown  somewhat  forward,  so  that  the  dorsum 
of  the  foot  is  strengthened.  On  palpation,  the  outline  of  the  astrag- 
alus can  be  made  out,  but  the  head  is  usually  buried  beneath  the  tibia. 
A  hollow  is  to  be  felt  between  the  malleoli  anteriorly.  The  bone  is 
often  displaced,  so  that  its  upper  articular  surface  looks  backward  with 
a  lateral  deviation,  especially  when  the  neck  has  been  fractured.  On 
manipulation,  there  is  no  movement  in  the  ankle-joint. 


SPECIAL   DISLOCATIONS.  657 

In  rotatory  displacements  inspection  offers  no  definite  signs ;  the 
diagnosis  is  one,  therefore,  of  exclusion,  aided  by  careful  palpation  for 
the  outline  of  the  astragalus.  On  manipulation,  there  is  little  move- 
ment at  the  ankle-joint. 

Diagnosis. — The  main  points  are  the  prominent  position  of  the  dis- 
placed bone,  the  outline  of  which  may  be  traced  on  palpation,  the  loss 
of  the  proper  relation  of  the  points  of  the  malleoli  to  the  astragalus 
and  the  sole  of  the  foot,  and  abolition  of  the  movements  of  flexion  and 
extension  at  the  ankle. 

Prognosis. — Complete  separation  of  the  astragalus  from  its  connec- 
tions may  be  followed  by  sloughing  of  the  skin,  especially  in  the  for- 


FlG.  319. — Backward  and  inward  dislocation  of  the  astragalus,  which  has  assumed  a  vertical 
position  (Sir  W.  MacCormac's  case). 

ward  variety.  In  the  backward  the  bone  finds  more  room  in  which  to 
accommodate  itself,  and  tension  is  not  so  extreme.  It  should  be  borne 
in  mind  that  when  complete  laceration  of  the  interosseous  ligament  has 
taken  place,  the  whole  of  the  vascular  supply  of  the  bone  has  been  cut 
off;  hence,  necrosis  is  not  uncommon.  In  the  backward  dislocations, 
the  foot  is  sometimes  fairly  useful,  even  if  the  bone  be  not  reduced ; 
but  in  the  forward  dislocations,  the  prominent  bone  on  the  dorsum  is 
so  painful  and  liable  to  injurious  compression  that  the  foot  is  often 
practically  useless. 

Treatment. — When  the  dislocations  are  simple  and  incomplete, 
attempts  at  reduction  are  always  to  be  made,  and  they  are  usually 
successful.  Reduction  is  effected  by  first  flexing  the  leg  on  the  thigh 
to  relax  the  tendo  Achillis ;  traction  is  then  made  on  the  foot,  and 
direct  pressure  on  the  astragalus.  If  necessary,  the  tendo  Achillis 
may  be  divided.  The  after-treatment  is  the  same  as  that  for  sub- 
astragaloid  dislocation.  When  complete,  if  not  readily  reducible, 
resection  of  the  bone  is  preferable ;  and  this  is  almost  without  excep- 
tion the  best  course  to  pursue  when  the  dislocation  is  compound. 

Dislocation  of  the  Other  Tarsal  Bones. — The  os  calcis  has  been 

42 


658  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

rarely  dislocated  alone,  generally  as  the  result  of  fixation  of  the  heel 
'in  falls;  the  cuboid  still  more  rarely,  as  a  result  of  direct  violence. 
The  scaphoid  occasionally  remains  attached  to  the  astragalus  and  sepa- 
rated from  the  cuneiform  bones  when  the  astragalus  is  displaced.  It  has 
also  been  displaced  with  the  three  cuneiform  bones,  or  again  with  the 
addition  of  the  two  inner  metatarsal  bones.  The  internal  cuneiform 
alone,  or  the  three  combined,  have  also  been  displaced.  All  these  dis- 
locations are  due  to  direct  violence,  usually  combined  with  twisting  of 
the  foot. 

Symptoms. — In  all,  the  displaced  bone  forms  an  abnormal  dorsal 
prominence,  and  in  the  case  of  all  except  the  os  calcis  the  foot  is 
shortened,  at  any  rate  on  the  affected  side.  If  left  unreduced,  a  weak- 
ened and  often  painful  foot  is  left.  A  general  rule  serves  for  the 
reduction  of  them  all :  The  foot  should  be  extended,  and  direct  press- 
ure made  on  the  displaced  bone.  The  after-treatment  consists  in 
fixation  for  at  least  six  weeks,  and  possibly  a  permanent  support  to 
the  sole.     If  reduction  is  impossible,  single  bones  are  best  resected. 

Metatarsus. — The  fixation  of  the  second  metatarsal  bone  in  the 
tarsus  makes  displacement  of  the  whole  series  almost  impossible, 
unless  either  the  second  bone  is  fractured  or  the  cuneiform  bones  are 
disturbed.  The  entire  metatarsus  is  occasionally  displaced,  either  on 
to  the  dorsal  or  plantar  aspect  of  the  tarsus,  and  with  one  or  other  of 
the  above  complications  in  an  inward  or  outward  direction. 

Symptoms. — When  backward  dislocation  occurs,  the  foot  is  short- 
ened, and  a  prominence,  with  a  groove  either  before  or  behind  it,  is  seen 
in  the  plantar  and  dorsal  displacements.  The  foot  is  usually  somewhat 
adducted,  and  the  hollow  of  the  sole  is  flattened. 

Lateral  displacements  are  always  accompanied  either  by  fracture  of 
the  second  bone,  or  displacement  of  the  internal  cuneiform,  when  the 
bones  pass  inward.  There  is  no  shortening  of  the  foot,  but  some 
adduction  or  abduction,  according  as  the  displacement  is  inward  or 
outward.  Reduction  is  usually  not  difficult,  but  considerable  weakness 
persists,  especially  in  the  lateral  displacements.  The  foot  should  there- 
fore be  kept  in  a  plaster-of-Paris  case  for  at  least  six  or  eight  weeks, 
and  a  support  for  the  arch,  preferably  a  Whitman's  brace,  may  be 
needed  permanently.  Compound  dislocations  of  these  joints  are  very 
uncommon.  The  first  or  fifth  bone  may  be  displaced  individually,  or 
groups,  such  as  the  fourth  and  fifth,  the  third  and  fourth,  or  the  second, 
third,  and  fourth. 

Metatarsophalangeal  and  Interphalangeal  Joints. — None  of  these 
displacements  is  common,  3  cases  are  recorded  in  the  series  of  1207, 
or  .24  per  cent.,  observed  at  St.  Thomas's  Hospital.  The  rarity  de- 
pends on  the  shortness  of  the  digits  and  their  protection  by  the  shoes. 
The  commonest  displacement  is  that  of  the  metatarsophalangeal  joint 
of  the  great  toe ;  and  this  corresponds  in  all  respects,  even  in  diffi- 
culty of  reduction,  with  the  corresponding  dislocation  of  the  thumb. 
Those  of  the  interphalangeal  joints  also  resemble  those  of  the  fingers. 
A  good  illustration  of  the  plantar  variety  is  often  seen  in  the  common 
deformity  of  hammer-toe.  The  mode  of  reduction  differs  in  no  way 
from  that  recommended  for  similar  injuries  to  the  hand. 


CHAPTER    XVIII. 
DISLOCATIONS  OF  THE  HIR 

Anatomy. — A  correct  understanding  of  the  anatomy  of  the  hip- 
joint  is  essential  to  the  recognition  and  reduction  of  the  various 
forms  of  dislocations  to  which  it  is  subject.  All  advances  in  our 
knowledge  of  these  dislocations  since  Hippocrates  have  been  almost 
entirely  due  to  a  clearer  recognition  of  the  bearing  of  the  anatomical 
structure  upon  the  mechanism  of  reduction. 

At  the  point  of  meeting  of  three  strong  buttresses,  the  ilium,  the 
ischium,  and  the  pubis,  the  firm,  rigid,  cup-like  acetabular  cavity 
receives  the  globular  head  of  the  femur.  It  lies  between  two  irregular 
bony  surfaces  produced  by  a  bend  in  the  innominate  bone,  meeting  at 
an  angle  of  about  90  degrees  the  ilio-ischiatic  and  pubo-ischiatic  surfaces, 
which  have  been  termed  by  Allis  the  outer  and  inner  planes  of  the 
pelvis.  The  dividing  ridge  between  these  two  planes  is  marked  by  a 
line  drawn  from  the  anterior  superior  spine  of  the  ilium  through  the 
tuberosity  of  the  ischium  (Fig.  320). 


«#\ 


Fig.  320. — Outer  and  inner  planes  of  the  pelvis  (Allis). 


In  all  dislocations  of  the  femur  the  head  will  escape  through  a  rent 
in  the  lower  portion  of  the  capsule,  the  strong  anterior  portion  remain- 
ing to  serve  as  an  important  agent  in  the  determination  of  the  signs  of 
dislocation  and  as  an  aid  to  reduction. 

Having  escaped  from  the  capsule,  the  head  slips  off  the  ridge  upon 
either  the  inner  or  outer  plane,  according  to  the  resultant  of  the  forces 
producing  the  dislocation  ;  and  upon  this  basis  is  made  the  rational 
classification  of  dislocations  into  inward  and  outward. 

The  capsule,  which  arises  from  the  entire  circumference  of  the  acetabular  rim  where  it 
is  thickest,  is  attached  to  the  anterior  intertrochanteric  line  in  front,  and  to  the  neck  of  the 

659 


66o 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


femur,  above  the  posterior  intertrochanteric  line,  behind.  Although  strong,  it  is  so  loose  that 
it  allows  all  ordinary  movements  of  the  joint  without  becoming  tense,  and  hence  plays  no 
part  in  holding  the  joint-surfaces  together. 

The  acetabular  socket  is  deepened  by  the  cotyloid  ligament,  a  firm,  elastic  cartilage, 
which  crowns  its  bony  rim,  forming  an  elastic  instead  of  a  rigid  cushion  to  check  too  free 
motion  of  the  femur,  and  which,  as  it  fits  air  tight  to  the  globular  head,  constitutes  a  sucker, 
enabling  atmospheric  pressure  to  maintain  the  integrity  of  the  joint.  The  bony  surfaces  are 
not,  however,  held  together  by  atmospheric  pressure  alone,  for  the  insertions  of  the  gluteus 
minimus,  iliacus,  and  psoas  magnus  muscles  are  such  as  to  enable  them  to  aid  in  making 
tense  the  capsule  and  giving  security  to  the  joint. 

The  ligamentum  teres,  a  rounded  cord  covered  by  synovial  membrane,  which  runs  from 
the  depression  in  the  head  of  the  femur  to  the  dome  and  transverse  ligament  of  the  acetab- 
ulum, and  to  which  so  many  varied  functions  have  been  ascribed,  is  now  believed  (Allis) 
to  be  only  a  distributer  of  synovia  to  the  dome  of  the  joint,  which  would  otherwise  be 
poorly  provided  with  lubricating  fluid.  It  is  loo  soft  and  yielding  to  serve  as  a  true  liga- 
ment, and  in  dislocations  is  generally  torn,  usually  from  the  head  of  the  femur,  and  often 
bringing  away  a  chip  of  periosteum  with   it. 


The  capsule,  which  extends  like  a  sleeve  from  the  rim  of  the  ace- 
tabulum to  its  insertion  into  the  neck  of  the  femur,  as  above  described, 
serves  (i)  to  restrain  the  movements  of  the  femur  within  safe  limits; 
(2)  to  furnish  surface  for  muscular  attachments ;  and  (3)  to  form  a  tight 
sac  to  retain  the  synovia  which  its  inner  surface  secretes.  It  presents 
three  thickenings,  the  first  and  most  important  of  which,  the  iliofemoral 
or  Y-ligament  (Fig.  321),  arises  from  the  anterior  inferior  spine  of  the 

ilium   and  is  inserted  into  the  anterior 
„.f,,     -\  intertrochanteric  line  of  the  femur,  the 

thickest  portions  of  the  insertion  spread- 
ing to  the  upper  and  lower  ends  of  the 
line  into  which  it  is  inserted,  like  the 
arms  of  a  Y.  Its  importance  in  the 
mechanism  of  dislocations  and  their 
reduction  was  first  elucidated  by  Bige- 
low,  and  subsequent  observers  have 
been  compelled  to  bear  witness  to  the 
accuracy  of  his  observations. 

Other  thickenings  of  less  importance 
in  dislocations  and  their  reduction  are 
the  ischiofemoral  ligament  and  the  pubo- 
femoral ligament.  The  former  passes 
from  the  ischial  portion  of  the  acetab- 
ular rim  on  the  back  of  the  joint  to  the 
posterior  surface  of  the  neck  of  the 
femur  and  the  posterior  intertrochan- 
teric line.  The  latter  arises  from  the 
pectineal  line  as  far  inward  as  the  spine 
of  the  pubis,  and  passes  outward  to 
blend  with  the  capsule,  being  continu- 
ous at  its  edge  with  the  iliofemoral 
ligament. 
The  fact  that  the  capsule  is  thickest  at  its  pelvic  attachment  gives 
it  strength  at  the  point  where  the  tension  must  be  greatest  when  the 
head  of  the  femur  is  pressed  against  it  in  a  dislocating  strain.  Close 
to  the  pelvic  attachment  the  head  will  impinge  upon  it,  and  it  is  here, 
therefore,  that  its   thickness   gives   it   greatest   resisting   power.     The 


Fig.  321. — The  Y-ligament  (Bigelow). 


DISLOCATIONS   OF   THE   HIP. 


66 1 


thickening  of  the  inner  and  outer  branches  of  the  Y  and  ischiofemoral 
ligaments  takes  place  at  the  points  where  greatest  strain  is  brought  to 
bear  upon  them  in  circumduction  of  the  joint,  the  strength  being  in 
proportion  to  the  resistance  required. 

The  femoral  vessels  are  rarely  injured  in  dislocations.  The  reasons  are — first,  that  they 
lie  on  the  upper  surface  of  the  joint,  and  dislocations  are  invariably  at  first  downward  ; 
second,  they  are  separated  from  the  joint  by  the  pectineus  and  iliopsoas  muscles,  which  con- 
tract and  lift  them  out  of  the  way  of  the  dislocated  head. 

The  fascia  lata,  while  it  plays  no  active  part  in  the  mechanism  either  of  dislocations  of 
the  hip  or  of  their  reduction,  has  an  important  function  in  holding  the  head  in  its  socket 
after  reduction.  In  normal  dorsal  recumbency  the  iliotibial  band,  extending  as  a  broad, 
unyielding  belt  from  the  crest  of  the  ilium  to  the  outer  side  of  the  head  of  the  tibia,  limits 
the  outward  rotation  of  the  leg  produced  by  gravity.  When  the  heels  of  the  patient  are 
tied  together  after  the  reduction  of  a  dislocation,  the  iliotibial  band  is  stretched  tightly 
across  the  great  trochanter  and  holds  the  head  of  the  femur  firmly  against  the  socket. 

When  the  femur  is  flexed  upon  the  pelvis,  the  sciatic  nerve  and 
hamstring  muscles  are  wound  across  the  back  of  the  hip-joint ;  and 
if  at  the  same  time  the  leg  is  extended  upon  the  thigh,  thus  separating 
the  origin  and  insertion  of  these  muscles,  they,  with  the  sciatic  nerve, 
are  tightly  stretched  across  the  back  of  the  neck  of  the  femur.  It  is 
in  the  position  of  flexion  of  the  joint  that  dislocations  of  the  hip  take 
place  and  are  reduced,  and  it  is  only  within  the  last  few  years  that 
attention  has  been  called  to  the  importance  of  the  relations  of  the 
nerve  and  muscles  to  these  dislocations  and  their  reduction.  Allis 
has  shown  experimentally  that  when  a  thyroid  is  transformed  into 
a  dorsal  dislocation,  the  head  of  the 
femur  must  pass  between  the  ham- 
string muscles  with  the  sciatic  nerve 
and  the  acetabulum,  and  that  the 
nerve  is  almost  always  more  or 
less  bruised  and  torn  away  from  its 
attachment  to  the  hamstring  tendon, 
and  sometimes  caught  and  forced 
backward  by  the  neck  of  the  femur 
(Fig.  322).  If  the  nerve  has  been 
so  separated  from  the  hamstrings, 
it  dangles  as  a  loose  cord  across 
the  opened  acetabulum ;  and,  if 
in  the  reduction  of  the  dislocation, 
which  has  now  become  dorsal,  a 
long  circumductive  sweep  is  em- 
ployed, and  especially  if  the  leg 
be  so  extended  on  the  thigh  as  to 
tighten  the  nerve,  there  is  danger 
that  the  nerve  may  be  actually 
caught  up  and  stretched  over  the 
front  of  the  neck  of  the  femur.  It 
is  then  so  shortened  that  full  exten- 
sion of  the  thigh  cannot  be  made.  This  condition  has  been  produced 
experimentally  by  Allis  and  verified  by  the  writers.  It  has  been  noted 
clinical ly  by  Allis  in  a  case  under  the  care  of  Koons  of  Philadelphia 
(Figs.  323,  324). 


FlG.  322. —  Relation  of  head  and  neck 
of  femur  to  hamstring  muscles  and  sciatic 
nerve  in  thyroid  dislocation  (Allis). 


662 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


To  the  obturator  interims  muscle,  to  its  strength,  and  its  importance  in  backward  dislo- 
cations in  preventing  the  head  of  the  femur  from   passing  up  upon  the  dorsum  ilii,  Bigelow 


FIG.  323. — Relation  of  head  and  neck  of  femur  to  sciatic  nerve  in  a  dorsal  dislocation  produced 

from  a  thyroid  (Allis). 

called  attention.     He  established  a  special  class  of  dorsal  dislocations,  called  dorsal  below 
the  tendon.     The  internal  obturator  has,  however,  been  so  frequently  found  ruptured   at 


PlG.  324. — Sciatic  nerve  pressed  up  by  neck  of  femur  in  reduction  of  a  dorsal  dislocation  pro- 
duced from  a  thyroid  (Allis). 

autopsies  and  in  experimental  work,  even  when  the  head  of  the  femur  had  a  low  position, 
that  Allis  is  inclined  to  ascribe  less  importance  to  it  in  determining  the  character  of  a  dis- 
location. 

Classification. — Allis's  classification,  based  upon  the  fundamental 
distinction  between  inward  and  outward  dislocation,  according  as  the 
head  rests  upon  the  inner  or  outer  plane  of  the  pelvis,  is  rational  and 
simple.  All  the  forms  enumerated  by  Bigelow — pubic,  subspinous, 
dorsal  below  the  tendon,  etc. — can,  as  Allis  has  shown,  be  brought 
under  the  heading  of  the  inward  or  thyroid  and  outward  or  dorsal  dis- 
locations. The  head  may  assume  a  high  or  low  position  after  it  has 
passed  out  upon  the  inner  or  outer  plane  of  the  pelvis.  A  brief  com- 
parative study  of  the  two  classifications  will  illustrate  the  comparative 
simplicity  of  Allis's  method  (see  page  663). 

Bigelow's  "  dorsal  below  the  tendon  "  becomes  the  "  low  dorsal  of 
Allis,"  his  "  pubic  and  subspinous  "  the  "  high  thyroid."  It  is  evident 
that  after  its  escape  from  the  capsule,  the  head  of  the  femur  may,  under 
the  influence  of  the  forces  which  are  effective  in  each  particular  case, 
come  to  rest  at  any  position  within  the  radius  allowed  by  the  distance 
from  the  origin  of  the  untorn  part  of  the  capsule  to  the  femoral  head. 


DISLOCATIONS   OF   THE   HIP. 


66- 


Bigelow's  Classification 

Allis's  Classification. 

I. 

2. 

Dorsal  high. 

Dorsal  below  the  tendon. 

I.   Thyroid  or  inward. 
a.   Low. 

3- 
4- 

Thyroid. 

Pubic  and  subspinous. 

b.  Middle. 

c.  High. 

5- 

Anterior  oblique. 

d.   Reversed. 

6. 

7- 

Supraspinous. 
Everted  dorsal. 

2.   Dorsal  or  outward. 

a.  Low. 

b.  High. 

c.  Reversed. 

"  Everted  dorsal  "  and  supraspinous  dislocations  are  simply  dorsal 
dislocations  in  which  the  outer  branch  of  the  Y-ligament  is  ruptured, 
allowing  in  the  former  case  eversion  of  the  leg  and  foot,  and  in  the 
other  allowing  the  head  of  the  bone  to  move  upward  and  hook  over 
the  intact  portion  of  the  ligament,  with  the  foot  everted.  These  both 
are  included  in  Allis's  more  accurate  term  "  reversed  dorsal." 

The  anterior  oblique  dislocation  of  Bigelow  is  probably  an  everted 
dorsal  dislocation,  in  which  the  outer  branch  of  the  Y-ligament,  unrupt- 
ured, engages  the  femoral  head  which  has  passed  above  it,  and  pre- 
vents the  leg  from   being  brought  parallel   with  its  fellow. 

Mechanism. — The  older  writers  on  the  subject,  up  to  and  including 
Bigelow,  have  held  that  the  chief  agent  in  the  production  of  disloca- 
tions of  the  hip  was  thrust — thrust  backward,  or  backward  and  upward 
with  the  thigh  flexed  in  dorsal  dislocations,  thrust  inward  with  the 
thigh  abducted  and  extended  in  thyroid  dislocations.  This  theory  of 
the  mechanism  was  perhaps  the  result  of  a  superficial  view,  suggested 
by  the  nature  of  the  accidents  by  which  dislocations  are  commonly  pro- 
duced. Such  accidents  as  the  catching  of  the  flexed  femur  between  two 
freight  cars,  a  fall  into  a  narrow  hole  upon  the  extended  leg  while  walking, 
etc.,  certainly  suggest  thrust  as  an  important  element  of  their  production. 

Allis  alludes  to  the  fact  that  no  experimenter  has  ever  been  able  to 
produce  dislocation  of  the  hip-joint  in  the  cadaver  without  previous 
tenotomy  of  the  capsule,  and  gives  methods  by  which  both  the  thyroid 
and  dorsal  dislocations  may  be  produced  experimentally  by  leverage. 
The  femur  is  the  lever  and  the  pelvis  the  fulcrum.  In  previous  experi- 
ments leverage  has  failed  to  produce  dislocations,  owing  to  imperfect 
fixation  of  the  pelvis.  In  the  production  of  traumatic  dislocations  in 
actual  life,  which  all  take  place  in  accidents  where  great  force  and  sud- 
denness are  combined,  the  inertia  of  the  body  under  the  influence  of 
the  sudden  twist  fixes  the  fulcrum — the  pelvis.  In  order,  then,  to 
imitate  nature  in  experimental  work,  it 
is  necessary  to  fix  the  pelvis  so  that  it 
may  serve  as  a  fulcrum.  This  Allis  did 
by  means  of  screws  and  cross-bars. 
He  found : 

i.  That  thyroid  dislocations  might 
be  produced  without  previous  tenotomy 
of  the  capsule,  simply  by  hyperabduc- 
tion  of  the  thigh  on  the  pelvis.  The 
great  trochanter  is  brought  against  the 
outer  part  of  the  acetabular  rim,  which 
offers  a  bony  fulcrum,  and  the  head  of  the  femur  is  pried  with  almost 


Fig.  325. — Thyroid  dislocation  by 
hvperabduction  (Allis). 


664  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

irresistible  force  through  the  lower  and  inner  portion  of  the  capsule 

(Fig-  325)- 

(  Bigelow '  alludes  to  abduction  as  entering  into  the  causation  of  this 

variety.) 

2.  That  dorsal  dislocations  may  be  produced,  if  the  pelvis  is  fixed, 
by  flexion  of  the  thigh,  adduction,  and  rotation  inward,  using  the  leg 
bent  at  the  knee  as  a  crank  for  the  production  of  rotation.  By  this 
maneuver  the  iliofemoral  ligament  is  wound  tightly  around  the  front  of 
the  neck  of  the  femur,  and  serves  as  a  fulcrum.  The  head  of  the 
femur,  rotated  against  this  fulcrum  stretched  across  the  neck,  with  the 
great  leverage  supplied  by  the  use  of  the  bent  leg  as  a  crank,  is  forced 
outward  through  the  tense  posterior  portion  of  the  capsule,  provided 
that,  as  sometimes  happens,  the  ligaments  of  the  knee  do  not  give  way 
under  the  strain. 

Attempts  to  dislocate  the  femur  by  flexion,  abduction,  and  rotation  outward — namely,  by 
using  the  bent  leg  as  a  lever  and  turning  it  inward — have  in  the  hands  of  Allis  proved  uni- 
formly unsuccessful.  The  pelvis,  the  ligaments  of  the  knee,  or  the  femur  itself  may  be 
fractured  ;  but  the  head  of  the  femur,  which  is  brought  directly  against  the  strong  anterior 
portion  of  the  capsule,  re-enforced  by  the  Y-ligament,  cannot  be  forced  through  that 
structure.  -^ 

Allis's  explanation  of  the  manner  in  which  leverage  may  be  shown 
to  explain  the  typical  accidents  resulting  in  dislocation  of  the  hip,  is  as 
follows  : 

The  first  case  is  that  of  a  man  who,  while  walking,  steps  into  a  long, 
narrow  hole,  and  falls  forward  upon  his  extended  leg.  These  condi- 
tions first  suggest  thrust ;  but  a  consideration  of  the  conditions  illus- 
trated by  Figs.  327,  328,  will  show  that  the  force  of  the  straightened  leg, 
acting  upon  the  inner  right-hand  corner  of  the  trunk  as  it  falls  for- 
ward, must  push  the  capsule  of  the  hip  upward,  backward,  and  out- 
ward— in  other  words,  must  produce  an  extremely  rapid  and  forcible 
flexion,  adduction,  and  inward  rotation.  Thus,  the  most  advantageous 
conditions  for  the  production  of  dorsal  dislocation  by  leverage  are 
produced. 

The  second  case  is  that  of  a  tramp  sitting  upon  the  narrow  foot-wide  platform  at  the 
rear  end  of  a  freight  car,  with  his  left  femur  extended  and  resting  upon  a  similar  platform 
of  the  following  car.  The  cars  come  together  as  the  train  slows  up,  and  his  left  femur  is 
dislocated  upon  the  dorsum  ilii.  Here  it  is  easy  to  see  that  the  force  explodes  suddenly 
upon  the  left-hand  corner  of  the  pelvis,  causing  flexion,  adduction,  and  rotation  inward 
(Figs.  326-328). 

A  man  shovelling  ballast  in  the  hold  of  a  ship,  standing  with  his  feet  between  the  ribs, 
and  stooping,  is  struck  upon  the  back  and  pelvis  by  a  cave-in  from  above.  A  dislocation  of 
both  femurs  is  produced,  one  outward  and  the  other  inward.  Here  the  body  is  flexed  upon 
the  thighs,  and  the  fixation  is  at  the  same  time  suddenly  increased  by  the  weight  falling  from 
above  ;  but  if  the  body  rotate  either  to  one  side  or  the  other,  the  legs  remaining  parallel, 
then  in  one  thigh  flexion,  adduction,  and  rotation  inward  are  produced,  with  flexion,  abduc- 
tion, and  rotation  outward  in  the  other.  In  this  way  a  dorsal  dislocation  of  one  hip  and  a 
thyroid  of  the  other  will  be  the  result. 

These  typical  cases,  then,  may  be  so  explained  as  to  support  the 
theory  of  Allis,  that  all  traumatic  dislocations  unaccompanied  by  fract- 
ure are  the  result  of  leverage. 

Pathology. — The  importance  of  the  almost  uniform  escape  from 
rupture  of  the  iliofemoral  ligament  in  dislocations  of  the  hip  was 
established  by  Bigelow  and  confirmed  by  all  subsequent  writers  ;  but 
1  Dislocations  of  the  Hip,  p.  70. 


DISLOCATIONS    OF   THE   HIP. 


665 


the  view  of  this  author  that  the  head  of  the  femur  frequently  escaped 
through  a  narrow  opening  or  slit  in  the  capsule,  which  might  require 
special  manipulations  in  order  that  it  might  be  made  to  gape  so  as  to 
allow  the  return  of  the  head,  has  not  been  confirmed.  The  results  of 
autopsies  and  the  experimental  work  of  Morris  and  Allis  have  shown 
that  the  head  of  the  femur,  in  escaping  through  the  capsule,  always 
makes  a  rent  ample  for  its  return.     The  reasons  for  this  are  the  inelas- 


FlG.  326. —  Illustrating  the  mechanism  of  case  2  (Allis). 


/fesisfance 


^ori 


FlG.  327. — Diagram  illustrating  cases  1  and  2  (Allis) 


FlG.  328. — Diagram  illustrating  cases  1  and  2  (Allis). 

tic  character  of  the  fibers  of  the  capsule,  the  spherical  shape  of  the 
head  of  the  femur,  and  the  explosive  character  of  its  rupture.  The 
buttonholing  of  the  head  by  the  capsule  is,  then,  only  an  imaginary 
obstacle  to  reduction. 

A  condition  which  is  of  the  greatest  practical  importance  (Allis), 
however,  is  the  position  of  the  rent  in  the  capsule.  This  rent  may  be 
(1)  at  the  pelvic  attachment  of  the  capsule,  (2)  obliquely  situated 
between  the  pelvic  and  femoral  attachments,  or  (3)  close  to  the  femoral 
insertion  of  the  capsule,  so  that  it  is  detached  like  a  sleeve  or  cuff 
extending  from  the  rim  of  the  acetabulum.     The  accompanying  figures 


666 


INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 


(Figs.  329-331)  illustrate  the  difference  between  these  positions  of  the 
capsular  rent;  and  it  is  evident  that  in  the  last  form  the  avulsed  capsule 
may  become  interposed  between  the  head  and  the  acetabulum  so  as  to 
fill  the  socket  and  prevent  reduction.  The  closer  the  rent  in  the  cap- 
sule lies  to  the  acetabular  socket,  the  less  will  be  the  likelihood  of  its 


FIGS.  329-331.—  Illustrating  the  three  forms  of  the  capsular  rent. 

interfering  with   reduction  by  becoming  folded  in ;  and  if  the  rent  is 
close  to  the  socket,  this  folding  in  cannot  take  place. 

The  injuries  to  muscles  in  dislocation  of  the  hip  result  either  from  overstretching  or  from 
direct  violence.  Those  due  to  overstretching,  which  are  frequently  produced  in  experimental 
work  upon  the  rigid  muscles  of  the  cadaver,  result  from  the  fact  that  the  limit  of  tension  of 
the  muscles  is  reached  before  the  capsule  is  ruptured  by  the  manipulations  employed.  In 
experimental  work  the  production  of  thyroid  dislocation  by  hyperabduction  is  attended 
by  rupture  of  the  adductor  longus,  gracilis,  and  pectineus.  The  pectineus  is  frequently 
found  ruptured  at  autopsies,  and  is  not  touched  by  the  head  of  the  femur  during  dis- 
location. 

By  direct  contact  with  the  head  of  the  femur  in  passing  from  a  dorsal  to  a  thyroid  posi- 
tion, or  from  the  inner  to  the  outer  plane  of  the  pelvis,  the  quadratus  femoris,  obturator 
externus,  and  a  few  of  the  short  upper  fibers  of  the  adductor  magnus  are  ruptured.  In 
dorsal  dislocations  the  obturator  internus  is  often  ruptured,  as  are  also  the  piriformis  and 
quadratus  femoris.  The  head  of  the  femur  may  pass  between  the  obturator  internus  and 
the  pyriformis  without  injury  to  these  muscles.1 

The  fact  that  in  this  form  of  dislocations  the  obturator  internus  is  often  found  to  be  rupt- 
ured or  avulsed  from  its  origin  renders  it  probable  that  too  much  importance  was  attached 
to  this  muscle  by  Bigelow  as  the  determining  factor  in  low  dorsal  dislocations. 

The  sciatic  nerve  has  been  twice  found  at  autopsy  torn  completely 
in  two,  and  has  frequently  been  reported  as  lacerated  or  bruised,  with 
more  or  less  separation  of  its  fibers.  It  has  been  frequently  hooked 
up  across  the  neck  of  the  femur  in  the  experimental  production  of 
dislocations. 

Partial,  complete,  temporary,  and  permanent  paralyses  have  resulted 
from  apparently  successful  reductions.  Rupture  of  the  outer  branch 
of  the  Y-ligament  allows  the  dorsal  dislocations  to  become  the  everted 
dorsal. 

The  older  writers  on  dislocation  of  the  hip  have  considered  the  rapid  healing  of  the  rent 
in  the  capsule  after  the  escape  of  the  head,  and  the  formation  of  adhesions  between  the 
capsule  and  the  acetabular  socket,  as  among  the  greatest  obstacles  to  the  reduction  of  dislo- 
cations. While  the  dislocation  persists,  however,  the  edges  of  the  torn  capsule  are  held 
apart,  so  that  there  can  be  little  danger  of  healing  ;  and  Allis  has  pointed  out  that  the  forma- 
tion of  adhesions  between  the  smooth  inner  surface  of  the  capsule  and  the  acetabular  socket, 
both  of  which  are  covered  with  epithelium,  is  extremely  improbable. 

1  The  possibility  of  the  head  of  the  femur  escaping  below  the  tendon  of  the  obturator 
internus  without  rupturing  the  latter  was  recognized  by  Bigelow,  and  considered  by  him  to 
determine  a  class  of*  dislocations  which  he  called  "dorsal  below  the  tendon."  These  are 
the  "low  dorsal  dislocations  of  Allis"  and  the  dislocations  into  the  sciatic  notch  of  Astley 
Cooper. 


DISLOCATIONS   OF   THE   HIP. 


667 


Whether  after  a  dislocation  inflammatory  changes  in  the  head  of 
the  femur  and  acetabulum  will  take  place  or  not,  will  depend  upon  the 
amount  of  violence  done  to  the  cartilages  at  the  time  of  the  injury.  In 
dislocations  by  simple  leverage,  the  head  and  socket  will  probably 
escape  without  bruising,  no  inflammatory  changes  are  likely  to  occur, 
and  a  new  socket  and  new  capsule  may  be  formed.  In  dislocations 
attended  by  crushing  of  the  cartilages,  such  as  might  result  from  direct 
violence,  inflammatory  changes  are  likely  to  take  place,  resulting  in  the 
adhesion  of  the  head  to  the  surrounding  parts  or  in  ankylosis.  The 
growth  of  osteophytes  in  the  torn  capsule  occasionally  takes  place,  and 
is  most  likely  to  occur  in  cases  where  more  or  less  periosteum  is  torn, 
together  with  the  capsule,  from  the  acetabular  rim. 

The  specimen  shown  in  Fig.  332  was  removed  at  autopsy  from  a  case  of  thyroid  dislo- 
cation of  the  hip,  which  had  remained  unreduced  for  years.  It  was  the  occasion  of  a  suit 
for  malpractice.  It  is  preserved  in  the  Warren  Museum  at  the  Harvard  Medical  School. 
As  shown  in  the  figure,  the  growth  of  osteophytes  around  the  head  of  the  femur,  which  was 
dislocated  into  the  obturator  foramen,  has  resulted  in  the  formation  of  an  almost  complete 
new  socket.    Marked  thickening  of  the  neck  of  the  femur  also  resulted  from  the  same  cause.1 


Fig.  332. — Old  thyroid  dislocation,  with  osteophytes. 

Signs  of  Dislocation. — Dorsal  or  Outward  Dislocation. — In  this, 
the  most  common  form  of  dislocation,  the  head  has  escaped  through 
the  posterior  part  of  the  capsule,  and  lies  with  the  neck  against  the 
outer  plane  of  the  pelvis ;  the  trochanter  is  thus  held  away  from  the 
bony  pelvis  and  cannot  be  made  to  touch  it.  According  to  Bige- 
low's  classical  description,  "the  limb  is  moderately  inverted,  a  little 
shortened,  and  advanced ;"  the  toes  cross  the  toes  or  the  instep  of 
the  other  foot,  according  to  the  degree  of  flexion  and  inversion,  and 
the  head  of  the  bone  may  generally  be  felt  upon  the  dorsum.  The 
inversion  is  chiefly  due  to  the  tension  of  the  outer  branch  of  the 
Y- ligament,  and  disappears  when  this  is  divided. 

When  extreme  flexion  is  present,  together  with  greater  inversion  and  advancement  of 
the  limb,  the  head  of  the  femur,  according  to  Bigelow,  is  caught  below  the  tendon  of  the 
obturator  internus,  and  to  this  dislocation  he  gives  the  name  of  "dorsal  below  the  tendon.'' 

1  Surgical  Observations,  J.  Mason  Warren. 


668 


INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 


The  variation  in  the  signs  according  to  the  high  or  low  position  of  the  head,  however, 
is  of  minor  importance.  The  inversion,  flexion,  and  adduction  are  the  inevitable  result  of 
the  relation  of  the  head  of  the  bone  to  the  fixed  pelvic  wall  and   the  tightened  Y-ligament ; 

and  these,  together  with  the  palpation  of  the  head 
in  its  abnormal  position  upon  the  dorsum  under  the 
glutei  muscles,  where  it  can  almost  always  be  felt, 
are  the  incontrovertible  signs  of  the  dorsal  or  out- 
ward dislocation. 

Thyroid  or  Inward  Dislocations. —  In 

this  class  the  characteristic  position  of 
the  limb  is  flexion  and  abduction,  the 
heel  being  raised  from  the  floor  and  the 
toe  pointing  outward  and  forward.  This 
position,  which  is  attended  by  marked 
constraint,  is  due  to  the  weight  of  the 
limb  holding  the  great  trochanter  against 
the  lower  rim  of  the  acetabulum,  the 
tightened  Y-ligament  acting  as  a  bridle 
and  preventing  complete  extension.  The 
great  trochanter  is  thus  brought  into 
close  contact  with  the  acetabulum,  lies 
deeply,  and  cannot  be  felt  (Fig.   335). 

In  the  "low  thyroid,"  the  "  dislocation 
near  the  tuberosity  or  perineum "  of 
Bigelow,  the  limb  will  of  necessity  be 
more  strongly  flexed,  in  order  that  the 
tight  Y-ligament  may  allow  the  low  posi- 
tion of  the  head. 

Bigelow's  "  dislocation  upon  the  pubis  " 

becomes   under   Allis's   classification  the 

high  thyroid  dislocation,  and  is  simply  a 

variety  of  the  inward  dislocation  charac- 

of  the  head  of  the  bone,  and   having  as 

and  erreater  shortening  and  eversion. 


Fig.  333. — Dorsal  dislocation  of  the 
hip.     Anterior  view. 


terized  by 
symptoms 


a  high   position 
less  marked  flexion 


Fig.  334. — Dorsal  dislocation  of  the  hip.     Lateral  view. 


The  thyroid  reversed  is  produced  from  the  simple  thyroid  dislocation  by  outward  rotation 
of  the  leg  until  the  head  of  the  femur  passes  in  front  of  the  Y-ligament  and  lies  in  front  of 
and  below  the  anterior  superior  spine  of  the  ilium.  In  this  variety  the  foot  may  be  everted 
so  far  that  the  toes  point  backward.  This  form  of  dislocation  is  rare,  due  to  extreme  vio- 
lence, and  usually  associated  with  other  injuries  of  a  severe  character. 


DISLOCATIONS    OF   THE   HIP. 


669 


Reduction. — Since  the  time  of  Hippocrates  flexion  of  the  hip- 
joint  had  been  recognized  as  an  important  step  in  the  procedures  for 
the  reduction  of  dislocations.  The  cause  of  the  characteristic  de- 
formity of  these  luxations,  however,  and  the  chief  obstacle  to  their 
reduction,  was  believed  to  be  the  contraction  of  the  powerful  muscles 
about  the  hip-joint.  Before  the  advent  of  anesthesia  the  want  of  a 
suitable  means  of  producing  muscular  relaxation,  and  the  ignorance  of 
the  manipulations  suited  for  reduction,  resulted  in  the  substitution  of 
great  force — applied  by  screws,  ropes,  and  pulleys — for  properly  directed 
manipulations.  As  this  powerful  extension,  which  was  found  necessary 
(as  it  was  supposed)  to  tire  out  the  contracted  muscles,  but  in  reality  to 
rupture  the  Y-ligament,  was  most  easily  applied  in  the  axis  of  the  body, 
longitudinal  traction  by  pulleys  was  the  method  taught  in  the  English 
school  at  the  beginning  of  this  century,  of  which  Astley  Cooper  was 
the  most  prominent  exponent.  The  blind  brute  force  thus  so  cruelly 
applied  was  the  cause  of  untold  suffering  and  of  permanent  damage  to 
many  hip-joints  during  the  period  that  this  method  was  taught.  Nathan 
Smith  and  William  W.  Reid  in  this  country  recognized  the  value  of 
flexion  and  manipulation  in  the  reduction  of  dislocations  of  the  hip, 
but  attributed  the  success  of  the  flexion  method  to  the  fact  that  it 
relaxed  the  contracted  muscles. 

To  Bigelow  is  due  the  credit  of  showing  that  the  Y-ligament,  and 
not  the  contraction  of  the  muscles,  was  the  chief  agent  in  producing 


FlG.  335- — Thyroid  dislocation  (Massachusetts General  Hospital, service  of  John  Homans,  M.D.). 

the  deformity  in  hip-dislocations  and  in  preventing  their  reduction  by 
longitudinal  traction,  and  that  its  aid  must  be  invoked  in  any  method 
for  their  easy  and  safe  reduction. 

Bigelow's  Methods  of  Reduction. — In  Bigelow's  methods  of  reduc- 
tion, which  have  stood  the  test  of  time  since  his  Memoir  was  published 


670 


INTERNATIONAL    TEXT-BOOK-  OF  SURGERY. 


in  1869,  advantage  is  taken  of  anesthesia  to  produce  muscular  relaxa- 
tion, and  the  positions  of  the  patient  and  surgeon  are  such  as  to  allow 
of  the  most  advantageous  application  of  his  strength.  The  etherized 
patient  lies  on  his  hack  on  the  floor.  The  surgeon,  standing  beside 
the  patient,  grasps  the  ankle  with  one  hand  ;  while  the  other,  placed 
beneath  the  head  of  the  tibia,  lifts  and  guides  the  limb  (Fig.  336).  The 
thigh  is  then  flexed  upon  the  abdomen,  and,  if  the  dislocation  is  dorsal, 
is  adducted  and  a  little  inverted,  to  disengage  the  head  of  the  bone 
from  behind  the  socket.  It  is  then  forcibly  lifted  or  jerked  upward, 
with  a  little  simultaneous  circumduction,  and  the  head  passes  into  the 
socket.  Or,  the  thigh  is  flexed  upon  the  abdomen,  and  then  simul- 
taneously, in  a  single  sweep,  abducted,  or  circumducted  and  rotated 
outward.  Bigelow  describes  the  maneuver  simply  in  the  phrase  "  lift 
up,  bend  out,  roll  out;"  or  "flex,  abduct,  evert."  This  circumductive 
sweep  Allis  has  shown  to  be  attended  by  danger  of  bruising  or  catch- 
ing up  the  sciatic  nerve,  which  his  new  methods  of  reduction  have 
been   designed  to  avoid. 

In  case  the  thigh  cannot  be  abducted  beyond  the  perpendicular, 
Bigelow  considers  that  the  head  of  the  femur  has  emerged  through  a 

too  small  orifice  in  the  capsule,  which, 
in  order  to  allow  of  its  return,  must  be 
circumducted  in  the  opposite  direction. 
This  circumduction  will  convert  the 
dorsal  into  the  thyroid  dislocation,  but 
will  enlarge  the  capsular  opening,  in 
his  opinion,  so  that  the  forcible  lifting 
with  the  thigh  flexed  can  hardly  fail 
to  effect  reduction.  The  fallacy  of  the 
view  that  the  head  ever  escapes  by  a 
slit  in  the  capsule  which  requires  en- 
largement has  been  pointed  out  earlier 
in  this  article,  and  the  danger  of  injury 
to  the  sciatic  nerve  by  the  circumduc- 
tive sweep  has  been  already  commented 
upon.  Upon  the  tightened  Y-ligament 
as  a  center,  the  head  of  the  femur,  with 
the  length  of  the  neck  for  a  radius,  is 
rotated  below  the  rim  of  the  acetabulum,  and  as  the  flexion  of  the 
thigh  carries  the  sciatic  nerve  across  the  back  of  the  joint,  may  easily 
catch  up  that  nerve,  especially  if  it  be  tightened  by  extension  of  the  leg 
at  the  knee.  This  has  been  repeatedly  demonstrated  by  experiment 
upon  the  cadaver,  and  has  probably  happened  in  actual  practice. 

For  reduction  of  thyroid  dislocations  Bigelow  recommended  a 
variety  of  methods.  The  two  methods  which  he  characterizes  by  the 
terms  "  rotation  "  and  "  traction  "  are  the  most  typical.  In  the  first 
method  he  flexes  the  limb  toward  the  perpendicular,  abducts  a  little  to 
disengage  the  head  of  the  bone,  then  rotates  the  thigh  strongly  inward, 
adducting  it,  and  carrying  the  knee  to  the  floor.  This  maneuver  is 
practically  the  reverse  of  the  flexion,  abduction,  and  eversion  employed 
to  reduce  the  dorsal  dislocation,  and  is,  in  fact,  flexion,  adduction,  and 


Fig.  336. — Reduction  of  dislocation  into 
the  thyroid  foramen  (after  Bigelow). 


inversion. 


DISLOCATIONS   OF   THE   HIP. 


671 


The  method  by  traction  consists  in  flexing  the  limb  and  drawing 
the  thigh  outward  by  a  towel  passed  around  its  upper  part,  or  thrusting 
it  outward  by  the  foot  applied  to  the  groin. 

Allis's  Methods. — These  methods  are  designed  to  make  the  head 
return  to  the  socket  by  the  path  by  which  it  escaped,  or  to  retrace  the 
steps  which  produced  the  dislocation,  without  exposing  the  sciatic 
nerve  or  other  contiguous  structures  to  danger  from  the  circumductive 
sweep  of  the  head  of  the  bone.  In  "  outward  dislocations  "  the  first 
step — retracing  the  last  step  of  the  dislocation — is  flexion,  in  addition 
to  which  it  may  be  necessary  to  add  traction  downward  to  free  the 
head  from  the  dorsum.  Next,  the  foot  is  turned  outward  (inward  rota- 
tion), so  that  in  the  next  motion — lifting — the  head  may  not  strike 
against  the  projecting  acetabular  rim  and  be  arrested  by  it.     Then  the 


FIG.  337. — Reduction  of  outward  or  dorsal  dislocation  by  Allis's  method. 


head  is  lifted  to  the  head  of  the  socket,  and  often  may  be  felt  to  catch 
on  the  tendon  of  the  hamstring  muscle,  or  the  sciatic  nerve,  or  both, 
as  it  is  lifted  past  them.  The  leg  is  next  turned  inward  to  throw  the 
femoral  head  outward  into  the  socket,  and  is  then  brought  down  in 
extension.  The  passage  of  the  head  into  the  socket  may  be  facilitated 
by  direct  pressure  by  the  thumbs  of  an  assistant 


672 


INTERNATIONAL    TEXT- BOOK   OF  SURGERY. 


The  method  may  be  tersely  expressed  as  follows  : 

1.  Flex,  turn  leg  out,  and  lift. 

2.  Turn  leg  in,  and  extend. 

For  dislocations  inward  Allis  gives  two  methods:  1.  The  Direct; 
and  2.  The  Indirect. 

In  the  direct  method  the  femur  is  first  flexed  and  abducted,  in  order 
to  bring  the  head  into  the  position  it  occupied  when  it  first  left  the 
socket ;  the  traction  outward  in  the  long  axis  of  the  femur  brings  the 
head  over  the  socket.  Direct  pressure  is  made  by  the  thumbs  of  an 
assistant  upon  this  head,  and  the  limb  adducted.  In  brief,  the  steps 
are : 

1.  Flex  and  abduct  the  femur. 

2.  Make  traction  outward. 

3.  Fix  the  head  by  digital  pressure  and  adduct. 

In  the  indirect  method  rotation  is  employed  to  carry  the  head  into 
the  socket. 

The  steps  are:  I.  Flex  the  thigh,  but  not  to  a  perpendicular  (this 
brings  the  head  into  the  position  it  occupied  when  it  left  the  socket). 

2.  Adduct  and  carry  the  knee  obliquely  downward  and  inward  (by 
this  movement  the  remnant  of  the  capsule  becomes  tense  and  draws 
the  head  upward  and  outward). 

3.  Rotate  outward — thus  turning  the  head  into  the  socket. 

By  these  methods  circumduction,  with  its  attendant  danger  of  injury 
to  the  sciatic  nerve,  is  avoided. 


FIG.  338. — 1.  Capsule  inverted.     2.  Capsule  caught.     3.  Capsule  everted. 


After=treatment. — The  after-treatment  which  should  follow  reduc- 
tion is  simple,  no  fixation  apparatus  being  required.  The  patient 
should  be  kept  in  the  dorsal  recumbent  position  for  three  weeks,  and 
the  heels  and  the  knees  should  be  tied  together  in  the  extended  posi- 
tion, thus  taking  advantage  of  the  "hammock"  function  of  the  ilio- 
tibial  band,  which  is  stretched  tightly  across  the  great  trochanter  and 
holds  the  head  of  the  femur  firmly  in  the  acetabular  socket. 

After  three  weeks  massage  and  passive  movements  may  be  em- 
ployed, and  the  patient,  aided  by  crutches,  may  cautiously  begin  the 
use  of  the  limb. 

Complications. — Cleaning  out  the  Socket. — Under  the  head  of 
Pathology  was  discussed  the  danger  of  the  capsule  being  caught 
between  the  head  of  the  femur  and  the  acetabular  socket  in  cases 
where  the  capsule  was  torn  off  close  to  the  rim  of  the  acetabulum. 
Not  merely  the  capsule,  but  shreds  of  torn  muscle  or  fascia  may 
become  interposed  between  the  head  and  the  acetabulum.  Allis  has 
pointed  out  that,  whether  muscle  or  capsule,  it  must  be  attached  to  the 


DISLOCATIONS    OF   THE   HIP. 


6/3 


pelvis,  and  not  to  the  femur.  If  one  side  of  the  head  of  the  femur  has 
driven  a  bit  of  capsule  before  it  into  the  socket,  the  opposite  side  must 
be  employed  to  turn  it  out,  as  is  evident  from  the  accompanying 
diagram  (Fig.  338). 

That  this  accident  has  happened  will  be  evident  in  practice  from  the 
fact  that  the  leg  cannot  be  brought  quite  down  into  position  ;  there  is 
slight  constraint,  and  the  motion  of  the  femur  is  somewhat  embarrassed. 
Allis  recommends,  if  the  capsule  has  been  pushed  in  from  the  dorsal 
side,  flexion  and  abduction ;  if  from  the  thyroid  side,  flexion  and 
adduction. 

These  manipulations  will  serve  to  catch  the  bit  of  capsule  on  the 
edge  of  the  femoral  head.    The  femur  is  then  rotated  inward  to  tighten 


Fig.  339. — Compound  dislocation  of  the  hip  (Cheever). 

the  Y-ligament,  and  the  knee  raised  to  the  median  plane  to  push  the 
foreign  tissue  out  of  the  socket. 

Entanglement  of  the  Sciatic  Nerve. — Under  the  headings  of 
Mechanism  and  Pathology  reference  has  been  made  to  the  danger 
of  catching  up  the  sciatic  nerve,  and  it  has  been  shown  how  the 
nerve  and  its  accompanying  hamstring  muscles  are  stretched  tightly 
across  the  back  of  the  joint  when  the  latter  is  flexed.  The  danger 
of  catching  the  nerve  across  the  neck  in  circumduction  has  been 
emphasized. 

The  diagnosis  of  this  condition  is  made  by  the  fact  that  the  leg  does 
not  come  down  into  full  extension,  and  a  tense  cord,  which  is  the 
stretched  nerve,  may  be  felt  in  the  popliteal  space. 

It  may  be  reduced  by  redislocating  the  femur,  turning  the  ankle 
of  the  flexed  leg  outward,  and  attempting,  by  rocking  and  shak- 
ing, to  make  the  nerve  drop  off  from  the  femoral  head,  the  head 
then  rotating  into  place  without  flexing  the  femur.  These  failing,  an 
open  incision  has  been  suggested  (Allis)  for  freeing  the  nerve  from 
its  position. 

Dislocation   with    Fracture  of  the   Shaft. — The  diagnosis  may  be 

4" 


674  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

difficult,  and  is  made  by  locating  the  upper  fragment  and  finding  that 
this  does  not  follow  the  rotatory  movements  of  the  shaft.  In  these 
conditions  we  are  able  to  employ  traction  alone  for  purposes  of  reduc- 
tion, leverage  being  evidently  out  of  the  question. 

Inward  dislocations  may  be  reduced  by  traction  outward,  with  direct 
pressure  upon  the  head.  This  may  be  supplemented,  if  unsuccessful, 
by  traction  inward  or  obliquely  inward  and  downward,  the  head  being 
held  beneath  the  socket  by  an  assistant  to  prevent  its  slipping  back 
into  the  thyroid  depression. 

Outward  dislocations  with  fracture  of  the  shaft  may  be  reduced  by 
first  bringing  the  head  to  the  level  of  the  socket  by  traction  directly 
upward,  followed  by  traction  upward  and  inward,  assisted  by  direct 
pressure  upon  the  head  by  an  assistant's  fingers. 

Compound  Dislocation. — This  is  a  rare  condition,  the  result  of 
great  violence,  and  usually  attended  by  other  serious  injuries.  The 
accompanying  illustration  (Fig.  339)  represents  a  case  in  which  resec- 
tion of  the  femoral  head  was  practised.  Death  resulted  from  the  con- 
comitant injuries. 


CHAPTER    XIX. 
DISEASES  OF  THE  BONES. 

INFLAMMATION. 

When  inflammation  attacks  a  bone,  it  docs  not  remain  limited  to 
one  part  of  the  bone.  Thus,  in  the  case  of  inflammation  attacking  the 
medulla  of  bone,  or  osteomyelitis,  we  have  also  inflammation  of  the 
dense  structure  of  the  bone,  or  osteitis,  and  very  commonly  inflamma- 
tion of  the  periosteum,  or  periostitis.  Conversely,  if  the  inflammation 
attacks  the  periosteum,  we  have  also  inflammation  of  the  dense  portion 
of  the  bone.  Hence  from  the  point  of  view  of  treatment  these  various 
conditions  must  be  considered  more  or  less  together. 

Inflammation  of  bone  may  be  acute  or  chronic.  Acute  inflammation 
of  bone  may  be  suppurative  or  non-suppurative.  Chronic  inflammation 
may  be  divided  into  simple  chronic  inflammation,  tuberculous  inflam- 
mation, and  syphilitic  inflammation. 

Acute  Nonsuppurative  Inflammation  of  Periosteum  and  Bone. — This  is  a 

very  rare  condition,  and  it  is,  as  a  matter  of  fact,  doubtful  whether  a  really  acute  inflamma- 
tion can  take  place  in  these  structures  without  suppuration.  A  form  of  periostitis  has  been 
described  by  Oilier  under  the  name  of  albuminous  periostitis,  in  which  exudation  occurs 
under  the  periosteum  of  a  serous  or  albuminous  nature  ;  but  this  affection  is  probably  only  a 
mild  or  early  stage  of  the  suppurative  form,  and  it  is  said  that  the  pyogenic  cocci  are  present 
in  the  exudation. 

The  changes  that  take  place  in  the  periosteum  under  these  circumstances  are  essentially 
the  same  as  those  in  acute  suppurative  periostitis.  There  are  redness,  swelling,  and  thicken- 
ing of  the  periosteum,  with  effusion  of  fluid,  followed  by  increase  in  the  thickness  of  the  bone 
after  the  acute  stage  of  the  inflammation  has  passed  off.  The  symptoms  are  intense  pain, 
fever  not  so  high  as  in  a  suppurative  form,  and,  if  the  bone  is  superficial,  some  redness  of 
the  skin  over  the  part.  The  treatment  is  essentially  the  same  as  in  the  suppurative  form, 
though  in  the  first  instance  one  might  continue  the  use  of  fomentations  for  a  longer  period 
than  in  the  case  of  acute  suppurative  periostitis. 

As  a  sequel  to  typhoid  fever,  periostitis  and  ostitis  are  not  at  all  uncommon,  and 
it  is  remarkable  for  what  a  length  of  time  the  typhoid  bacillus  can  apparently  live  in  the 
tissues.  In  some  cases  the  periostitis  does  not  go  on  to  suppuration,  and  usually  attacks  the 
more  superficial  bones,  such  as  the  tibia.  In  other  cases,  however,  suppuration  may  occur. 
The  favorite  habitat  of  the  typhoid  fever  in  connection  with  bones  is  the  medulla,  and  sup- 
puration of  a  chronic  character  may  occur  in  the  medulla,  ultimately  perforating  the  dense 
shell  of  the  bone  and  forming  an  accumulation  outside  ;  and  in  the  pus  of  these  abscesses 
nothing  but  a  pure  cultivation  of  the  typhoid  bacillus  may  be  found.  We  have  known  of 
cases  where  the  typhoid  bacillus  has  been  present  and  active  for  several  years  after  the  onset 
of  the  disease. 

The  treatment  in  these  cases  of  suppuration  in  connection  with  typhoid  fever  must  be 
very  thorough,  and  one  must  especially  bear  in  mind  the  fact  that  the  bacillus  is  most  com- 
monly situated  in  the  medulla.  The  medullary  cavity  of  the  bone  should  therefore  be 
opened  up  and  thoroughly  scraped  out,  even  if  it  involve  the  scraping  out  of  the  whole  of  the 
cavity  from  top  to  bottom.     Usually,  if  that  is  done,  the  wounds  heal  without  further  trouble. 

Acute  Suppurative  Inflammation  of  Bone. — This  is  usually 
spoken  of  as  acute  osteomyelitis,  because  the  inflammation  almost  always 
begins  in  the  medulla  of  the  bone ;  in  a  few  cases,  however,  the  deeper 
part  of  the  periosteum  is  the  primary  seat  of  the  process. 

675 


676  INTERNATIONAL    TEXTBOOK  OF  SURGERY. 

Acute  suppurative  osteomyelitis  is  an  acute  suppurative  inflammation 
of  the  medulla  of  the  bone,  which  occurs  especially  in  young  subjects, 
and  which  may  be  accompanied  by  general  infection  of  the  body.  It  is 
due  to  the  pyogenic  organisms,  more  especially  to  the  Staphylococcus 
pyogenes  aureus,  and  the  disease  may  arise  without  any  open  wound  in 


FlG.  340. —  Acute  osteomyelitis  of  the  tibia  (Nichols). 

the  vicinity,  or  after  an  open  wound  such  as  amputation  or  a  compound 
fracture.  When  the  disease  commences  without  any  external  wound, 
the  organisms  must,  of  course,  be  deposited  in  the  part  from  the  blood, 
and  to  account  for  their  presence  in  the  blood  one  usually  finds  some 
preceding  inflammatory  condition  elsewhere,  such  as  a  boil.     In  many 


IA  -JL  A  MM  A  TION.  &77 

cases,  apparently,  the  organisms  gain  access  to  the  blood  in  connection 
with  an  intestinal  catarrh,  and  the  disease  is  not  uncommon  after  chol- 
era and  acute  intestinal  disturbances.  As  to  the  deposit  of  the  organ- 
isms at  the  particular  part  affected,  there  is  very  often  some  history  of 
local  injury.  The  disease  occurring  spontaneously  almost  always 
attacks  the  bone  in  the  immediate  vicinity  of  the  epiphysis,  where  the 
circulation  is  slower  and  where  it  has  been  shown  that  solid  particles 
floating  in  the  blood  are  very  apt  to  be  deposited,  the  commonest  seats 
being  the  lower  end  of  the  femur,  the  upper  end  of  the  tibia,  the  upper 
end  of  the  humerus,  and  the  lower  end  of  the  radius.  Of  the  cancel- 
lous bones,  the  os  calcis  near  the  epiphyseal  line  is  perhaps  most  fre- 
quently affected.  In  some  cases  the  suppurative  inflammation  begins 
beneath  the  periosteum ;  but  usually  the  suppuration  under  the  perios- 
teum is  secondary  to  osteomyelitis. 

The  result  of  acute  inflammation  in  the  medulla  of  the  bone  is 
that  the  part  becomes  greatly  congested,  fluid  is  poured  out  which  fills 
up  the  cancellous  spaces  and  Haversian  canals,  and  subsequently  accu- 
mulates under  the  periosteum,  the  medulla  very  quickly  becomes  infil- 
trated with  pus,  the  periosteum  thickened  and  swollen,  and  pus  also 
forms  beneath  it  (Fig.  340).  The  suppuration  under  the  periosteum 
may  result  without  any  communication  with  the  medulla,  or  in  some 
cases  only  after  the  bone  has  become  softened  at  some  part,  and  a 
communication  is  thus  established. 

In  young  children  the  disease  may  remain  localized  in  the  neighborhood  of  the  epiphyseal 
cartilage,  and  is  then  spoken  of  as  acute  epiphysitis.  This  condition  may  very  quickly  lead 
to  destruction  of  the  cartilage,  or  at  any  rate  to  a  solution  of  continuity  between  the  epiph- 
ysis and  the  diaphysis.  More  commonly,  however,  a  greater  or  less  portion  of  the  shaft 
also  becomes  involved. 

If  the  patient  lives  and  no  surgical  treatment  is  adopted,  this  condi- 
tion almost  always  results  in  death  of  a  greater  or  less  portion  of  the 
bone,  hence  the  term  "  acute  necrosis."  The  part  of  the  bone  which 
dies  [9  essentially  the  dense  shaft,  and  it  may  involve  the  whole  circum- 
ference or  even  the  whole  length  of  the  diaphysis,  or  it  may  be  limited 
to  a  small  portion  in  the  vicinity  of  the  epiphysis  ;  it  may  also  involve 
the  whole  thickness  of  the  shaft,  or  only  a  part  of  the  central  or 
peripheral  portion.  Suppuration  soon  occurs  beneath  the  periosteum, 
and  the  abscess  later  on  bursts  externally,  and  subsequently  fresh 
abscesses  and  openings  may  form.  So  long  as  the  dead  bone  remains, 
these  abscesses  refuse  to  heal,  and  sinuses  continue  which  lead  down  to 
the  sequestrum.  When  the  abscess  bursts,  the  severity  of  the  inflam- 
mation usually  subsides,  and  then  processes  go  on  which  lead  to  the 
separation  of  the  dead  bone. 

The  symptoms  of  acute  osteomyelitis  depend  on  the  virulence  of 
the  causal  organisms  and  on  the  extent  and  situation  of  the  disease. 
In  any  case  there  are  usually  violent  fever  and  great  pain  in  the  first 
instance  ;  but  the  fever  soon  passes  into  the  typhoid  type,  being  accom- 
panied by  a  rapid  small  pulse,  headache,  thirst;  dry  tongue,  stupor  or 
delirium,  so  that  the  disease  is  at  this  stage  often  mistaken  for  typhoid 
fever  or  meningitis.  The  pain  is  generally  intense,  and  if  the  bone  is 
superficial,  swelling  is  soon  apparent  over  it,  the  skin  also  becoming 
red  or  livid.  In  the  course  of  a  few  days  fluctuation  becomes  evident, 
and  on  incision  pus  escapes ;  the  bone  is  felt  to  be  bare  in  parts,  while 


6j$  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

in  others,  though  not  actually  bare,  the  periosteum  peels  off  very 
readily.  Where  the  bone  is  more  deeply  seated,  or  where  the  process 
is  confined  to  the  medulla,  the  swelling  and  redness  may  not  appear  so 
early ;  but  in  any  case  the  pain  is  extremely  severe,  so  long  as  the 
patient  is  sufficiently  conscious  to  refer  to  it.  In  young  children  it  often 
happens  that  it  is  only  more  or  less  accidentally  that  one  finds  a  par- 
ticular bone  which  is  affected,  especially  where  the  patient  is  in  a  state 
of  stupor.  Under  such  circumstances  the  patient  does  not  call  any 
special  attention  to  the  part,  and  it  is  these  cases  which  are  often  so 
extremely  difficult  to  diagnose.  In  severe  cases  the  symptoms  are  very- 
grave  indeed,  and  may  end  in  death  in  two  or  three  days  from  rapid 
septicemia,  while  in  others  the  patient  may  survive,  and  die  subsequently 
of  pyemia,  septicemia,  ulcerative  endocarditis,  exhaustion,  etc.  When 
the  disease  is  in  the  neighborhood  of  the  epiphysis,  the  joint  in  the 
vicinity  often  becomes  inflamed  and  swollen,  though  not  necessarily 
suppurating. 

Prognosis. — If  suppuration  occurs  in  the  joint,  the  prognosis  is 
very  grave.  The  prognosis  also  depends  to  a  very  great  extent  on  the 
treatment ;  early  and  vigorous  treatment  may  save  even  very  grave 
cases.  Under  any  circumstances,  however,  the  prognosis  is  grave, 
as  regards  both  the  immediate  and  subsequent  results,  the  certainty 
being  that  at  the  best  the  patient  will  have  a  long  illness,  that  he  may 
have  serious  derangement  of  the  neighboring  joint,  and  that  deficiency 
in  growth,  often  with  great  deformity,  may  result. 

So  far,  we  have  been  speaking  of  acute  suppurative  inflammation 
of  bone  as  it  arises  spontaneously;  but  in  other  cases  the  disease  may 
follow  wounds  of  bones  such  as  amputations,  compound  fractures,  etc. 
Under  these  circumstances  the  infection  spreads  up  through  the  medul- 
lary cavity,  and  also  frequently  under  the  periosteum  at  the  same  time, 
and  the  result  is  that  if  the  patient  lives,  there  is  usually  necrosis  of 
the  greater  part  of  the  bone,  extending  upward  for  a  considerable  dis- 
tance along  the  shaft,  and  not  infrequently  small  independent  seques- 
tra are  found,  especially  toward  the  central  part  of  the  bone.  The 
symptoms  here  are,  of  course,  similar  and  equally  grave,  but  the  diag- 
nosis is  more  easily  made,  because  attention  is  at  once  directed  to  the 
part  where  the  inflammation  is  taking  place. 

Diagnosis. — These  cases  of  osteomyelitis  and  acute  epiphysitis  must 
be  diagnosed  from  a  number  of  other  diseases,  more  especially  from 
typhoid  fever  and  meningitis,  from  acute  rheumatism,  from  an  abscess 
outside  the  bone,  and,  in  the  less  acute  forms,  from  non-suppurative  in- 
flammation, tuberculosis,  and  other  diseases.  As  regards  the  diagnosis 
from  typhoid  fever,  etc.,  that  difficulty  only  arises  in  the  very  acute 
forms  where  there  is  rapid  poisoning  of  the  patient,  and  where  he 
cannot  therefore  give  an  account  of  his  symptoms,  and  more  espe- 
cially in  young  children  who  are  not  able  to  tell  what  ails  them.  In 
cases  of  this  character,  where  symptoms  set  in  so  acutely  and  rapidly, 
one  should  suspect  a  septicemic  condition  rather  than  a  specific  fever, 
such  as  typhoid  fever ;  and  in  all  suspicious  cases  one  ought  to  feel 
over  the  body,  especially  over  the  bones  usually  affected,  to  see  whether 
pain  is  caused  or  not ;  if  the  child  winces,  a  local  cause  is  at  once  mani- 
fest.    In  the  case  of  osteomyelitis,  also,  the  pressure  of  the  bone  in  an 


TNFL  A  MM  A  T10N.  679 

upward  direction,  such  as  tapping  on  the  feet  in  cases  of  osteomyelitis 
of  the  tibia  or  femur,  causes  pain. 

In  acute  rheumatism  the  symptoms  are  more  general,  a  number  of 
joints  are  affected,  and  on  the  whole  the  condition  of  the  patient  is 
not  so  bad  as  in  osteomyelitis.  The  temperature  in  the  first  instance 
is  not  so  high,  nor  does  the  patient  pass  into  the  typhoid  state.  A 
deep-seated  abscess  will  rarely  give  rise  to  any  great  trouble.  It  does 
not  usually  produce  the  violent  constitutional  symptoms,  especially 
the  typhoid  state  of  acute  osteomyelitis.  When  the  abscess  is  in  the 
leg,  tapping  the  foot  will  not  usually  increase  the  pain  unless  the 
inflamed  part  itself  is  touched  or  moved. 

The  treatment  of  acute  suppurative  inflammations  of  bone  must 
be  considered  according  to  the  stage  of  the  disease  and  the  part  of  the 
bone  which  is  more  especially  affected,  according  to  the  presence  or 
absence  of  suppuration  in  the  neighboring  joints,  and  according  to 
whether  it  has  followed  an  open  wound  or  not. 

Acute  suppurative  periostitis  is  extremely  rare ;  but  if  in  a  case 
where  the  symptoms  have  lasted  for  only  two  or  three  days  it  is 
found,  on  cutting  through  the  periosteum,  that  a  large  abscess  is  pres- 
ent, it  is  possible  that  the  disease  is  limited  to  the  subperiosteal  tissue, 
and  it  may  be  well  to  remain  content,  at  any  rate  for  twenty-four 
hours,  with  free  incision  through  the  periosteum.  This  incision  should 
be  extremely  free,  and  it  is  well  to  wash  out  the  pus  in  these  cases. 
When  it  is  possible  that  the  medulla  may  not  be  affected,  it  is  inadvis- 
able to  open  up  the  bone  at  the  time  of  the  first  operation,  otherwise 
it  might  become  infected  and  the  state  of  matters  be  made  very  much 
worse ;  but  if,  after  twenty-four  hours,  it  is  found  that  the  grave  symp- 
toms still  continue  without  relief,  it  is  an  indication  that  the  disease 
was  not  limited  to  the  periosteum,  but  affects  the  medulla  of  the  bone, 
and  therefore  under  these  circumstances  the  patient  should  be  again 
anesthetized,  and  the  medulla  of  the  bone  thoroughly  opened  up  in  the 
manner  immediately  to  be  described. 

The  treatment  of  acute  osteomyelitis  consists  in  freely  opening  up  the 
medullary  cavity  and  clearing  out  all  the  pus  and  medullary  tissue. 
As  soon  as  the  diagnosis  has  been  made,  a  free  incision  should  be 
made  down  to  the  bone,  the  periosteum  turned  to  one  side,  and,  with 
a  chisel  and  hammer,  the  dense  shell  of  the  bone  cut  away  till  the 
medullary  cavity  has  been  well  opened  up  and  all  the  soft  material 
thoroughly  scraped  out.  The  incision  in  the  bone  must  be  extended 
until  the  whole  affected  area  of  bone  has  been  exposed ;  but  in  cases 
where  the  whole  diaphysis  is  affected,  it  may  be  more  convenient  to 
make  several  openings  in  the  bone  and  to  scrape  out  the  cavity  between 
them,  rather  than  to  make  one  large  gutter.  Seeing,  however,  that  a 
large  portion  of  the  bone  will  probably  die,  there  is  no  particular  harm 
in  gouging  away  a  large  amount,  for  one  may  actually  remove  the 
whole  of  the  necrosed  portion  in  this  way.  After  having  thoroughly 
cleaned  out  the  whole  of  the  medullary  cavity,  it  should  be  sponged 
with  undiluted  carbolic  acid,  and  drainage-tubes  inserted.  A  little 
cyanid  gauze  may  also  be  introduced  between  the  edges  of  the  wound 
and  between  the  drainage-tubes,  so  as  to  prevent  closure  of  the  wound 
in  the  first  instance.  The  limb  should  be  placed  on  a  splint.  If  after 
three  or  four  days  it  is  found  that  the  wound  is  aseptic,  the  stuffing 


680  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

may  be  left  out,  and  only  one  or  two  drainage-tubes  retained  at  the 
angles  of  the  wound,  the  rest  being  stitched  up. 

In  cases  where  the  whole  of  the  diaphysis  is  dead  and  separated  at 
the  epiphyseal  line,  it  may  be  removed,  the  periosteum  being  left 
intact ;  and  under  such  circumstances  a  certain  amount  of  bony  for- 
mation may  occur  from  the  detached  periosteum,  sufficient  sometimes, 
where  there  are  two  parallel  bones,  to  give  stability  to  the  limb.  If  a 
sufficient  amount  of  bone  docs  not  develop,  bone-grafting  must  subse- 
quently be  employed  ;  but  this  cannot  be  carried  out  unless  the  wound 
is  aseptic.  In  most  cases  it  is  best  to  delay  bone-grafting  until  the 
wound  has  quite  healed,  and  then  subsequently  to  open  up  the  parts 
again  with  the  view  of  introducing  the  grafts. 

In  the  after-treatment  one  must  remember  the  tendency  of  the  neighboring  joints  to 
become  stiff  as  the  result  of  inflammation  in  the  joints  themselves,  leading  to  adhesions  and 
obliteration  of  portions  of  the  synovial  capsule,  as  well  as  of  inflammatory  exudation  around 
the  joint,  giving  rise  to  fibrous  adhesions  around  it,  and  of  adhesion  of  tendons  to  the  bone. 
With  the  view  of  avoiding  these  troubles,  the  splint  should  not  be  continued  too  long,  and 
after  two  or  three  weeks  massage  and  passive  motion  of  the  neighboring  joints  and  muscles 
should  be  carried  out.  In  the  case  of  the  lower  extremity,  it  is  well  to  keep  the  patient  in 
bed  so  long  as  there  is  a  prospect  of  the  wound  healing  ;  but  if  it  is  evident  that  a  sequestrum 
is  present,  there  is  no  particular  object  in  keeping  him  in  bed,  and  his  strength  will  be  better 
maintained  by  allowing  him  to  get  about.  As  regards  the  upper  extremity,  of  course,  the 
patient  need  not  be  kept  in  bed  at  all  after  the  fever  subsides. 

Among  the  chief  risks  of  acute  osteomyelitis  are  septicemia  and 
pyemia,  and  in  spite  of  free  and  early  operation  some  patients  still  suc- 
cumb to  these  diseases.  As  regards  pyemia,  if  symptoms  of  that 
disease  appear,  such  as  rigors,  etc.,  one  should  examine  the  state  of  the 
main  veins  of  the  limb,  with  the  view  of  seeing  if  any  of  them  are 
thrombosed  and  can  be  cut  off  from  the  general  circulation.  In  many 
cases,  however,  the  septic  thrombosis  affects  the  smaller  veins  either  in 
the  bones  or  just  as  they  leave  the  bones,  and  it  is  hardly  possible  to 
carry  out  what  seems  to  be  the  only  promising  treatment  of  pyemia — 
viz.,  the  removal  of  a  portion  of  the  vein  beyond  the  thrombosed  part 
and  the  clearing  out  of  the  clot.  Hence  in  these  cases,  when  pyemia 
declares  itself,  the  question  of  amputation  must  be  carefully  considered, 
and  if  amputation  can  be  carried  out  without  marked  shock  to  the 
patient,  and  above  the  seat  of  the  thrombus,  it  gives  the  patient  the 
best  chance.  If  thrombosed  veins  are  found  in  the  stump,  they  should 
be  followed  up  and  removed  at  a  point  beyond  the  thrombosed  area. 

In  cases  of  septicemia,  on  the  other  hand,  there  is  no  particular 
advantage  in  amputation,  because  under  those  circumstances  the  affec- 
tion generally  spreads  beyond  the  region  of  the  bone.  Hence  in  septice- 
mia we  can  only  see  that  the  suppurating  part  is  thoroughly  opened 
up,  cleared  out,  and  disinfected,  and  carry  out  the  rest  of  the  treatment 
on  the  lines  indicated  in  speaking  of  septicemia. 

In  cases  of  acute  epiphysitis,  which  especially  occurs  in  children,  the 
epiphyseal  cartilage  is  very  apt  to  be  completely  destroyed,  and  as  the 
result  no  further  growth  of  the  bone  takes  place  ;  thus  very  material 
shortening  of  the  limb  may  result  as  the  patient  grows  up.  As  regards 
the  treatment  of  the  acute  stage  of  epiphysitis,  we  have  nothing  to  add 
to  what  has  been  already  said  with  regard  to  acute  osteomyelitis  gener- 
ally. Free  incisions  must  be  made  down  to  the  part  as  soon  as  pos- 
sible, the  periosteum   divided,  and  the  bone  gouged  away  on  the  dia- 


INFLAMMATION.  68 1 

physeal  side  of  the  epiphysis,  so  as  to  open  up  the  region  thoroughly. 
The  only  point  to  which  we  need  refer  in  connection  with  acute 
epiphysitis  is  the  deficient  growth  of  the  bone  afterward — -a.  condition 
which  is  not  only  very  serious  as  causing  shortening  of  the  limb,  but 
which  is  particularly  troublesome  where  one  of  two  parallel  bones  is 
affected,  leading  in  that  case  to  great  deformity  of  the  foot  or  hand. 
With  the  view  of  remedying  this  deformity,  some  surgeons  have  pro- 
posed that  in  cases  of  acute  epiphysitis  of  one  of  two  parallel  bones  it 
would  be  well  to  destroy  the  epiphyseal  cartilage  of  the  healthy  bone. 
The  great  objection  to  such  a  procedure  in  the  early  stage  is  that  one 
cannot  at  first  be  quite  sure  that  the  cartilage  is  entirely  destroyed. 
Where,  however,  two  or  three  years  have  elapsed,  and  it  is  evident  that 
no  growth  is  taking  place,  this  suggestion  is  well  worth  considering. 
The  alternative  procedure  is  to  allow  the  bone  to  grow  and  the  deform- 
ity to  take  place,  and  then  to  cut  down  and  excise  portions  of  the 
longer  bone,  so  as  to  bring  the  foot  or  hand  straight  again.  The 
decision  as  to  which  of  these  procedures  should  be  adopted  depends 
essentially  on  the  age  of  the  patient  when  first  attacked  by  the  disease 
— i.  c,  on  the  amount  of  growth  which  has  yet  to  take  place,  and  the 
consequent  degree  of  deformity.  If,  for  example,  several  years  have  to 
elapse  from  the  occurrence  of  the  disease  to  the  completion  of  growth, 
the  chances  of  getting  a  useful  result  from  taking  out  a  portion  of  the 
elongated  bone  are  comparatively  slight,  at  any  rate  if  one  waits  till 
growth  is  complete,  because  by  that  time  the  joint-surfaces  will  have 
become  altered,  accommodated  to  the  new  state  of  matters,  and  will 
not  readily  take  up  a  fresh  position ;  and  further,  the  tendons  and 
muscles  and  other  structures  will  all  have  become  short  in  accordance 
with  the  deformity.  Hence,  if  this  method  of  procedure  is  to  be 
carried  out,  it  should  be  done  long  before  the  bone  has  attained  its  full 
growth,  and  should  be  repeated  if  necessary.  Under  some  circum- 
stances, however,  the  first  plan  is  often  the  best. 

Where  we  have  acute  suppurative  inflammation  of  bone  accompanied 
by  suppuration  in  the  neighboring  joints,  we  have  to  do  with  a  very 
serious  condition,  and  one  which  often  ends  fatally.  These  are  usually 
cases  of  acute  epiphysitis.  Under  such  circumstances,  the  first  thing 
that  one  thinks  of  is  the  advisability  of  amputation,  and  in  most  cases, 
if  the  patient  is  seen  before  his  condition  has  become  hopeless,  ampu- 
tation through  the  bone  above  is  the  best  treatment.  In  some  cases, 
however,  where  the  symptoms  are  not  so  severe,  one  may  be  content 
with  opening  up  the  medulla,  as  already  described,  and  in  addition 
making  free  incisions  into  the  joint  so  as  to  expose  thoroughly  and 
evacuate  every  recess,  subsequently  draining  the  joint  for  a  time,  and 
if  necessary  employing  constant  irrigation. 

As  regards  acute  suppurative  osteomyelitis  and  periostitis  resulting 
after  an  open  wound,  we  meet  with  this  at  all  ages,  and  the  age  of  the 
patient  is  of  very  great  importance  in  determining  the  method  of  treat- 
ment. Under  these  conditions  the  organisms  at  once  spread  into  and 
along  the  medulla  and  under  the  periosteum  with  great  rapidity,  and 
lead  almost  certainly  in  the  case  of  an  amputation-stump  to  complete 
necrosis  of  the  lower  end  of  the  stump,  and  very  often  to  the  forma- 
tion of  sequestra  higher  up.  This  condition  is  also  extremely  apt  to 
be  accompanied  with  pyemia ;  and  in  the  case  of  a  stump  the  piece 


682  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

of  bone  which  is  left  is  very  often  not  worth  saving,  at  any  rate  not 
worth  risking  the  patient's  life  to  save.  Hence  the  proper  procedure 
in  acute  necrosis  following  amputation-wounds  seems  to  be  early  am- 
putation through  the  joint  above. 

In  the  cases  of  compound  fractures  where  osteomyelitis  has  set  in, 
unless  the  condition  is  very  limited,  amputation  is  usually  the  best 
practice ;  but  in  some  cases  where  the  disease  is  quite  limited  and  the 
patient  is  young,  one  may  delay  and  wait  for  the  separation  of  seques- 
tra, and  in  this  way  get  a  satisfactory  limb. 

Necrosis  of  bone  follows  acute  suppurative  osteomyelitis  and 
periostitis,  and  may  also  result  from  tuberculous  disease,  syphilis,  the 
action  of  phosphorus,  etc.,  Here  we  shall  only  consider  the  sequestra 
which  follow  acute  suppurative  osteomyelitis.  In  this  case  the  seques- 
tra present  the  character  of  the  normal  dense  bone,  which  dies  before 
any  alteration  has  taken  place  in  it.  Once  a  piece  of  bone  has  died, 
it  must  become  separated  from  the  living  by  a  process  of  granulation 
and  suppuration  ;  the  living  bone  in  the  immediate  vicinity  of  the  dead 
gradually  becomes  soft  as  the  result  of  rarefying  osteitis,  and  ultimately 
the  solid  part  of  the  bone  disappears  and  its  place  is  taken  by  granula- 
tion-tissue. When  once  the  whole  of  the  living  bone  in  immediate 
contact  with  the  dead  has  been  converted  into  granulation-tissue,  sup- 
puration takes  place  at  the  point  of  contact,  and  then  the  piece  of  dead 
bone  comes  to  be  loose,  lying  in  a  cavity  lined  with  granulation-tissue. 
The  time  required  for  the  separation  of  the  dead  piece  of  bone  varies 
from  six  weeks  to  six  months,  according  to  the  density  and  vitality  of 
the  bone  affected.  During  the  process  of  separation  of  the  dead  bone, 
condensation  of  the  bone  around  takes  place,  and  new-formation  of 
bone  goes  on  actively  from  the  periosteum,  which  has  been  detached, 
and  from  the  surface  of  the  bone  at  the  point  of  junction  of  the  living 
and  the  dead.  Hence,  while  the  sequestrum  is  becoming  loose,  new 
bone  is  being  formed  extensively  around  it,  till  by  the  time  the  seques- 
trum is  detached  it  lies  in  a  cavity  formed  partly  of  new  bone,  two  or 
three  holes  termed  cloacae  being  left  in  the  new  case,  through  which 
the  pus  escapes.  The  dead  fragment,  if  of  any  size,  cannot  escape 
through  the  holes  that  are  left  in  the  bony  case,  and,  although  small 
portions  may  become  broken  off  and  gradually  work  their  way  to  the 
surface,  the  main  sequestrum  lies  there  unless  it  is  removed  by  artificial 
means.  So  long  as  it  remains,  suppuration  is  kept  up  around  it ;  the 
inflammatory  condition  of  the  bone  continues  ;  there  is  steadily  increas- 
ing condensation  of  the  bone,  and  steadily  increasing  thickness  of  the 
bony  case  which  covers  it.  In  the  flat  bones,  however,  such  as  the 
skull,  the  production  of  new  bone  is  not  nearly  so  marked,  and  there 
is  very  seldom  anything  like  complete  enclosure  of  the  dead  fragment 
in  a  bony  cavity. 

The  symptoms  indicative  of  the  presence  of  dead  bone  are,  in  the 
first  instance,  a  previous  history  of  acute  illness,  followed  by  the  for- 
mation of  an  abscess  in  a  few  days  or  by  an  incision  by  a  surgeon,  and 
subsequently  by  sinuses  which  remain  open  for  years.  The  granula- 
tions around  the  openings  are  generally  prominent.  The  bone  itself 
at  the  seat  of  the  necrosis  is  very  much  thickened,  and  the  tissues  are 
adherent  to  tthe  periosteum.  On  introducing  a  probe,  one  feels  bare 
bone,  which  may  or  may  not  move,  according  to  the  size  and  shape  of 


INFLAMMATION.  683 

the  sequestrum  and  the  cavity  in  which  it  lies.  Whether  the  dead 
piece  is  felt  to  move  or  not,  if  we  have  the  acute  history,  and  if  a  period 
of  at  least  six  months  has  elapsed  since  the  onset  of  the  trouble,  we 
may  be  pretty  sure  that  the  dead  piece  has  become  separated.  Even 
though  we  may  not  be  able  to  find  bare  bone,  it  is  certain  to  be  there 
under  the  circumstances  mentioned,  and  the  failure  to  find  it  simply 
means  that  the  sinus  is  tortuous  or  that  the  opening  in  the  new  case  is 
too  small  to  admit  the  probe. 

Treatment. — During  the  period  which  intervenes  between  the  attack 
of  acute  illness  and  the  separation  of  the  sequestrum,  there  is  no 
object  in  any  surgical  interference  ;  for  if  one  cuts  down  at  that  time, 
it  is  difficult  to  be  certain  how  much  of  the  bone  is  dead  and  where 
the  point  of  contact  of  the  dead  and  the  living  is.  Therefore,  up  to 
the  time  when  the  bone  has  become  separated  by  natural  processes, 
all  that  one  need  do  is  to  apply  antiseptic  ointments  to  the  orifice  of 
the  sinuses  and  to  see  that  proper  escape  of  discharge  is  provided. 
When  a  suitable  time  for  operation  has  arrived,  the  first  point  for  con- 
sideration is  how  we  can  get  as  free  access  to  the  dead  bone  as  possi- 
ble ;  and  if  the  sinuses  are  situated  in  parts  where,  on  account  of  the 
presence  of  nerves,  vessels,  etc.,  we  cannot  make  a  free  enough  open- 
ing, we  should  disregard  the  sinuses  altogether  and  cut  down  on  some 
other  part  of  the  bone  where  the  anatomical  arrangements  are  more 
favorable.  The  incision  in  the  skin  should  be  coextensive  with  the 
thickening  of  the  bone,  because  it  is  absolutely  essential  that  the  whole 
cavity  in  which  the  bone  lies  should  be  freely  opened  up,  both  with  the 
view  of  making  certain  that  the  whole  fragment  is  removed,  and  also 
with  the  view  of  providing  proper  escape  of  discharge  afterward  and 
of  obtaining  proper  closure  of  the  cavity.  The  skin  and  tissues  are 
therefore  divided  freely,  the  periosteum  detached  laterally  over  the 
thickened  area,  so  as  to  give  free  access,  and  then  with  a  chisel  and 
hammer  one  proceeds  to  chisel  away  the  bone  till  one  reaches  the 
cavity  where  the  sequestrum  is  present.  Where  the  patient  is  weakly, 
it  is  in  most  cases  advisable  to  apply  a  tourniquet  before  the  operation, 
both  with  the  view  of  preventing  unnecessary  loss  of  blood,  and  also 
with  the  view  of  being  able  to  disinfect  the  cavity  thoroughly  after- 
ward. Having  reached  the  cavity  in  the  bone,  it  should  be  opened  up 
completely  from  end  to  end  and  from  side  to  side  till  the  sequestrum 
can  be  lifted  out  without  any  trouble.  Having  removed  the  sequestrum 
and  thoroughly  scraped  out  all  the  granulation-tissue,  one  should  also 
dissect  out  the  sinuses  which  lead  to  the  diseased  bone,  and  then  pro- 
ceed to  disinfect  the  parts  in  the  hope  of  obtaining  asepsis.  The  part 
should  be  thoroughly  sponged  with  undiluted  carbolic  acid,  and  after 
this  has  acted  for  a  few  minutes,  the  cavity  should  be  tightly  packed 
with  gauze  sprinkled  with  iodoform.  The  tourniquet  can  then  be 
relaxed,  and  any  superficial  vessels  which  spout  can  be  tied  and  the 
rest  of  the  wound  filled  up  with  packing.  An  antiseptic  dressing  is 
applied  outside,  and  in  many  cases  one  in  this  way  succeeds  in  render- 
ing the  wound  aseptic. 

An  important  point  in  the  after-treatment  is  to. decide  what  is  to  be 
done  as  regards  the  large  cavity  left  behind.  If  the  septic  condition  is 
not  eradicated,  the  stuffing  can  be  taken  out  in  two  or  three  days,  and 
the  best  thing  to  do  then  is  to  stitch  together  the  skin-incision,  with  the 


684  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

exception  of  an  opening  at  one  end  through  which  a  large  drainage- 
tube  passes  into  the  cavity.  When  we  find  on  dressing  the  wound 
after  three  or  four  days  that  there  is  no  suppuration  whatever,  the  stuff- 
ing should  be  completely  removed,  and  an  attempt  may  be  made  to  fill 
up  the  cavity  with  material  which  will  become  organized,  either  blood- 
clot  alone,  or  catgut,  or  decalcified  bone-chips.  Of  these  methods,  the 
best  is  bone-grafting  by  means  of  decalcified  bone-chips.  These  bone- 
chips  are  decalcified  and  kept  in  a  solution  of  corrosive  sublimate  in 
alcohol.  The  cavity  is  filled  up  with  the  bone-chips,  a  little  bleeding  is 
induced,  so  that  the  intervals  between  the  chips  become  filled  with  blood- 
clot,  and  then  the  periosteum,  if  possible,  is  brought  together,  a  stitch 
or  two  put  in  between  the  muscles,  and  the  skin-wound  closed.  A 
drainage-tube  is  not  usually  required  unless  excessive  bleeding  is  pres- 
ent, in  which  case  a  few  strands  of  catgut  brought  out  at  the  lower  end 
of  the  wound  will  allow  the  superfluous  blood  to  escape.  The  wound  is 
covered  with  an  antiseptic  dressing,  and  the  part  placed  at  rest  on  a  splint. 
As  regards  the  after-treatment  of  operations  for  necrosis,  one  must 
remember  that  if  the  limb  is  kept  at  rest  too  long,  not  only  may  the 
neighboring  joints  become  stiff,  but  the  muscles  are  very  apt  to  become 
adherent  to  the  edge  of  the  opening  in  the  bone,  and  also  to  become 
thickened  and  matted  together.  Therefore,  from  quite  an  early  period 
massage  should  be  employed.  This,  however,  must  be  more  carefully 
done  in  cases  where  bone-grafting  has  been  employed,  otherwise  the 
young  organizing  material  may  be  broken  up  and  organization  pre- 
vented. At  the  same  time  it  should  be  remembered  that  the  patient 
has  been  pulled  down  by  the  previous  illness,  and  nourishing  diet  and 
the  best  hygienic  conditions  employed.  The  administration  of  iron, 
especially  in  the  form  of  Blaud's  pills  or  capsules,  is  of  importance ; 
the  condition  of  the  urine  must,  of  course,  be  watched,  and  so  on. 
While  this  is  the  general  rule  of  treatment  in  young  persons,  in  old 
people  amputation  is  frequently  advisable,  and  it  may  also  be  required 
in  young  persons  where  the  health  is  much  broken  down,  the  kidneys 
diseased,  etc. 

Sir  James  Paget  has  referred  under  the  name  of  "  quiet  necrosis"  to  a  condition  in  which 
necrosis  of  bone  "occurs  without  any  violent  inflammation  and  without  the  formation  of  sinuses 
leading  to  the  sequestrum.  These  cases  are  rare,  and  it  is  probable  that  a  good  many  of 
them  are  examples  of  tuberculous  disease  of  bone.  Cases  are  seen,  however,  and  I  have 
met  with  them,  where  on  chiselling  up  a  mass  of  inflamed  bone  a  sequestrum  is  found  in  the 
interior  ;  but  the  only  interest  in  these  cases,  from  the  point  of  view  of  treatment,  is  to 
remember  that  when  one  is  opening  up  bone  thickened  as  the  result  of  chronic  inflammation, 
one  should  be  on  the  lookout  not  only  for  a  chronic  abscess,  but  also  for  a  piece  of  dead  bone. 

Chronic  Periostitis  and  Osteomyelitis. — In  addition  to  the 
acute  forms  of  inflammation  of  bone,  we  may  have  inflammation  of  a 
more  chronic  type  affecting  either  the  periosteum  or  the  medulla  and 
adjacent  dense  bone.  This  condition  may  in  some  cases  follow  the 
acute,  but  more  usually  it  is  chronic  from  the  first.  In  the  case  of 
chronic  periostitis  the  result  is  great  thickening  of  the  periosteum  itself 
and  marked  formation  of  new  bone  underneath  it,  and  also  great  con- 
densation of  the  pre-existing  bone.  In  the  case  of  chronic  osteomye- 
litis the  result  is  either  softening  of  the  bone,  "  rarefying  osteitis  "  or 
condensation  of  the  bone,  "  condensing  osteitis,"  or  a  localized  abscess 
in  the  bone,  "  Brodie's  abscess."  In  some  rare  cases,  as  has  just  been 
mentioned,  a  sequestrum  has  also  been  found. 


INFLAMMATION.  685 

As  to  the  etiology  of  chronic  periostitis  and  osteomyelitis,  it  some- 
times occurs  after  an  injury,  in  other  cases  in  connecton  with  some  con- 
stitutional condition,  such  as  rheumatism,  or  again  under  circumstances 
which  we  do  not  exactly  understand.  We  exclude  here  chronic  inflam- 
mation dependent  on  tuberculosis  or  syphilis. 

As  regards  the  symptoms  of  chronic  periostitis  and  osteomyelitis, 
we  have  very  marked  thickening  of  the  bone  in  the  region  of  the  dis- 
ease, and  tenderness  over  the  inflamed  part,  generally  acute  at  certain 
points.  There  is  often  a  great  deal  of  pain,  which  is  worse  when  the 
limb  becomes  warm,  and  more  especially  when  the  patient  is  in  bed  at 
night.  The  tenderness  is  usually  more  marked  in  chronic  periostitis 
than  in  chronic  osteomyelitis ;  while,  on  the  other  hand,  in  chronic 
osteomyelitis  the  pain  is  more  marked  than  the  tenderness,  and  is 
especially  of  a  neuralgic  and  throbbing  character.  In  both  cases  the 
symptoms  may  subside  at  times  and  again  get  worse,  the  course  being 
marked  by  exacerbations  and  remissions ;  sometimes  even  for  months 
the  patient  may  be  comparatively  free  from  pain,  and  then  again  suffer 
from  a  severe  attack.  In  cases  where  we  have  Brodie's  abscess  of  bone, 
the  disease  is  generally  in  the  neighborhood  of  the  epiphysis,  there  is 
marked  enlargement  at  the  part,  the  pain  is  of  a  very  intense  character, 
especially  at  night,  and  there  is  generally  a  tender  spot  somewhere  or 
other.  Sometimes,  indeed,  where  the  disease  has  lasted  long  and 
where  the  bone  has  become  softened,  we  may  also  find  a  soft  spot. 

The  treatment  of  these  conditions  is  either  palliative  or  radical. 
Palliative  treatment  consists  in  rest  to  the  part,  elevation,  the  employ- 
ment of  counterirritation  in  the  form  of  either  blisters  or  the  actual 
cautery,  especially  Corrigan's  cautery,  and  the  administration  of  drugs 
internally,  of  which  the  chief  are  potassium  iodid  and  salicin  or  sodium 
salicylate.  Apart  from  the  possible  syphilitic  origin  of  some  of  these 
cases,  large  doses  of  potassium  iodid  seem  to  relieve  the  pain  in  some 
cases  very  markedly — doses,  for  instance,  commencing  with  10  grains 
three  times  a  day,  and  rapidly  going  up  to  20  or  30  grains.  The  result 
of  this  palliative  treatment  is  usually,  however,  only  temporary,  and  it 
is  but  seldom  that  a  cure  results,  even  though  the  treatment  be  contin- 
ued for  many  months.  As  a  rule,  the  patient's  condition  improves  for 
a  time,  and  he  may  keep  pretty  well  while  taking  large  doses  of  potas- 
sium iodid ;  but  if  he  begins  to  walk  about,  and  especially  if  he  leaves 
off  his  iodid,  the  old  symptoms  are  extremely  apt  to  recur. 

Hence  in  cases  where  a  sufficient  trial  has  been  given  to  palliative 
measures  without  much  benefit,  it  is  advisable  to  propose  an  operation. 
The  operative  procedures  consist  in  cutting  down  on  the  inflamed 
part  and  removing  as  far  as  possible  the  whole  of  the  thickened  and 
inflamed  periosteum,  gouging  away  a  large  portion  of  the  thickened 
bone,  and  looking  for  the  presence  of  an  abscess  or  sequestrum  or 
other  cause.  Strict  asepsis  is  imperative.  If  an  abscess-cavity  is  found, 
it  should  be  thoroughly  opened  up  in  the  manner  described  in  speaking 
of  sequestra  ;  it  is  well  to  sponge  out  the  cavity  afterward  with  undiluted 
carbolic  acid.  After  the  operation  the  wound  should  be  stitched  up 
closely  and  healing  by  first  intention  aimed  at.  With  the  view  of  getting 
a  better  scar,  one  should  use  curved  incisions,  turning  aside  a  flap,  rather 
than  a  straight  incision  over  the  center  of  the  inflamed  area.  Afterward 
the  limb  should  be  put  in  a  splint  for  two  or  three  weeks,  because  the 


686 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


cavity  in  the  bone  fills  with  blood-clot  which  must  become  organized. 
In  cases  where  the  inflammation  is  at  some  distance  from  a  joint,  this 
splint  may  be  continued  even  longer.  When  the  splint  is  left  off,  the 
patient  should  still  be  kept  in  bed,  if  it  is  the  lower  extremity  which  is 
the  seat  of  the  disease,  for  six  weeks  or  a  couple  of  months,  so  as  to 
allow  the  new  tissue  to  become  thoroughly  firm.  If  the  patient  gets 
up  too  early,  the  young  vessels  in  the  organizing  blood-clot  give  way, 
hemorrhage  takes  place,  and  the  process  of  organization  is  apt  to  be 
arrested.  Massage  and  passive  movement  should  be  kept  up  from  an 
early  period  after  the  operation. 

TUBERCULOUS  DISEASE  OF  BONE. 
The  parts  of  the  bone  affected  with  tuberculous  disease  are  chiefly 
the  cancellous  ends  (Fig.  341),  either  the  epiphysis  itself  or  the  shaft 


FlG.  341. — Miliary  tubercle  of  bone;  on  the  right,  beginning  separation  of  sequestrum. 

outside  the  epiphyseal  line.  In  other  cases,  however,  the  medulla  of 
the  shaft  may  become  affected,  or  again  the  disease  may  begin  beneath 
the  periosteum.     The  disease  may  assume  the  following  forms : 

1.  Acute  Tuberculosis  of  Bone. — -This  may  occur  in  the  course  of  a 
general  acute  tuberculosis,  or  may  be  limited  to  one  bone,  arising  in 
connection  with  a  tuberculous  deposit  at  one  part  of  the  bone.  The 
form  which  occurs  in  acute  general  tuberculosis  is  not  of  clinical 
importance  ;  but  where  the  outbreak  is  limited  to  one  bone,  it  influences 
the  treatment  in  so  far  that  nothing  short  of  removal  of  the  affected 
bone  is  likely  to  do  any  good. 

2.  Limited  deposits  of  tuberculous  material  may  occur  in  bones, 
especially  in  the  epiphysis  or  in  the  diaphysis  in  the  immediate  neigh- 
borhood of  the  epiphysis.     They  may  present  the  form  of  soft  caseat- 


TUBERCULOUS  DISEASE    OF  BOXE. 


687 


r 


ing  deposits  in  which  the  trabecular  of  the  bone  have  more  or  less 
completely  disappeared,  or  of  sequestra  which  lie  embedded  in  tuber- 
culous material,  and  which  are  denser  and  heavier  than  the  normal 
bone,  but  easily  broken  up  and  very  slow  in  separating. 

3.  Tuberculous  osteomyelitis,  where  the  medullary  tissue  of  the 
bone  becomes  infiltrated  with  tuberculous  material.  This  condition 
especially  affects  the  short  long  bones,  such  as  the  phalanges  and 
metacarpal  bones ;  and  in  the  fingers  it  is  known  as  "  strumous  dactyl- 
itis!" It  is  also  the  most  common  form  of  tuberculosis  in  the  small 
cancellous  bones. 

4.  Tuberculous  periostitis,  in  which  the  tuberculous  material  is 
deposited  beneath  the  periosteum.  This  form  especially  occurs  in  con- 
nection with  the  ribs  and  the  vertebrae,  and  the  result  of  the  disease  is 
that  the  bone  becomes  eroded,  and  in  the  case  of  the  ribs  may  be 
almost  completely  destroyed,  and  undergo  fracture.  At  the  same  time 
the  tuberculous  material  is  apt  to  spread  outward  and  form  abscesses 
in  the  soft  tissues. 

As  regards  the  further  history  of  the  tuberculous  deposits  in  bone, 
the  tendency  is  for  the  disease 
to  spread ;  softening  of  the 
bone  occurs,  and  by  and  by 
the  deposit  reaches  the  surface. 
In  cases  where  the  epiphysis  is 
affected,  the  opening  on  the 
surface  may  occur  either  into 
the  joint  itself,  in  which  case  it 
is  followed  by  acute  disease  of 
the  joint,  or  outside  the  limits 
of  the  synovial  membrane. 
The  cases  in  which  the  deposit 
reaches  the  joint  (Fig.  342)  are 
discussed  under  the  head  of 
Tuberculous  Disease  of  Joints 
(p.  713).  When  it  reaches  the 
surface  outside  the  capsule  of 
the  joint,  it  leads  to  infection 
of  the  periosteum  and  subse- 
quently of  the  soft  tissues,  and 
to  the  formation  of  a  chronic 
abscess,  which,  when  opened, 
is  found  to  lead  down  to  an 
opening  in  the  bone,  and 
through  this  opening  to  the 
tuberculous  deposit  in  the 
bone. 

As  regards  the  etiology 
of  these  cases,  the  ultimate 
cause  is  the  tubercle  bacillus, 
but  the  localization  of  the  dis- 
ease in  a  bone  is  very  often 
brought  about  by  the  occurrence  of  some  slight  injury.     These  cases 


Fig.  342. 


-Tuberculous  disease  of  the  knee-joint 

with  ankylosis. 


688  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

occur  especially  in  children  and  young  adults,  the  tendency  to  tuber- 
culous deposits  in  the  bone  being  greater  in  children,  while  in  adults 
tuberculous  periostitis  is  more  common. 

The  symptoms  of  tuberculous  disease  of  bone  are  in  the  early 
stage  often  very  obscure ;  indeed,  the  disease  may  have  advanced  to  a 
considerable  extent  before  the  patient's  attention  is  attracted  to  it.  In 
the  case  of  tuberculous  deposits  toward  the  ends  of  bones,  the 
patient  may,  for  weeks  preceding  the  occurrence  of  any  marked  symp- 
toms, have  noticed  an  indefinite  aching,  or  even  only  a  feeling  of  tired- 
ness, in  the  limb,  and  a  disinclination  to  go  about  as  much  as  usual, 
but  no  acute  pain.  Later  on,  some  enlargement  of  the  affected  portion 
of  the  bone  occurs,  and  the  aching  becomes  somewhat  more  marked, 
but  it  in  no  way  resembles  the  pain  and  aching  which  are  characteristic 
of  a  simple  chronic  osteomyelitis  or  periostitis.  On  examining  the 
part,  some  enlargement  of  the  bone,  usually  limited  to  one  side,  may 
be  found,  and  possibly  also  a  little  tenderness  on  pressure.  If  the 
disease  has  existed  for  some  time,  one  may  come  across  a  point  where 
the  tenderness  is  more  marked  and  where  a  certain  amount  of  soften- 
ing can  be  felt.  If  that  is  the  case,  it  indicates  the  point  where  the 
tuberculous  deposit  is  making  its  way  out  of  the  bone.  When  chronic 
abscess  has  formed  outside  a  bone,  accompanied  by  enlargement  of  the 
bone  and  preceded  by  these  indefinite  symptoms,  the  diagnosis  is  at 
once  clear,  because  the  occurrence  of  a  chronic  abscess  in  connection 
with  bony  enlargements  is  practically  pathognomonic  of  tuberculosis. 
Under  no  other  circumstances  that  I  know  of  does  chronic  abscess 
occur,  unless  possibly  in  actinomycosis.  Where  the  case  is  one  of 
tuberculous  periostitis,  the  diagnosis  is  generally  made  much  sooner,  on 
account  of  the  early  formation  of  a  chronic  abscess. 

In  the  case  of  tuberculous  osteomyelitis  of  the  short  long  bones, 
such  as  the  phalanges,  the  appearance  is  very  characteristic.  The 
patient  is  almost  always  a  child ;  very  often  several  bones  are  affected, 
and  the  enlargement  of  the  bone  is  of  a  spindle-shaped  character.  In 
the  early  stage  there  is  no  softening  or  pain,  and  later  on  the  presence 
of  an  abscess  adds  to  the  certainty  of  the  diagnosis.  In  this  case  the 
only  difficulty  will  arise  in  connection  with  hereditary  syphilis,  because 
in  syphilis  one  meets  with  a  somewhat  similar  condition.  There,  how- 
ever, the  condition  arises  usually  in  infancy,  other  symptoms  of  syph- 
ilis are  present,  and  abscess-formation  does  not  occur.  In  the  case  of 
tuberculous  osteomyelitis  of  the  cancellous  bones,  such  as  the  tarsal 
bones,  beyond  the  feeling  of  uneasiness  and  aching  in  the  early  stage, 
the  patient  does  not  usually  notice  anything  till  the  disease  has  attacked 
the  neighboring  joints.  The  symptoms  of  disease  of  the  tarsus  will 
therefore  be  left  till  the  discussion  of  Tuberculous  Diseases  of  Joints. 

As  regards  the  treatment,  it  will  hardly  be  necessary  to  treat 
separately  of  tuberculous  deposits,  tuberculous  osteomyelitis,  and  tuber- 
culous periostitis.  The  most  convenient  way  is  to  speak  of  tuberculous 
disease  of  bone  without  abscess,  tuberculous  disease  of  bone  with 
abscess,  and  tuberculous  disease  of  bone  with  septic  sinuses. 

i.  Tuberculous  Disease  without  Abscess. — Where  there  is  no 
abscess  the  difficulty  is  to  diagnose  the  existence  of  tuberculous  dis- 
ease ;  but  having  decided  that  this  is  present,  the  question  lies  between 


TUBERCULOUS  DISEASE    OF  BONE.  689 

palliative  and  radical  measures.  Under  palliative  measures  we  include 
rest  to  the  part,  counterirritation,  pressure,  good  hygienic  conditions, 
country  air,  cod-liver  oil,  syrup  of  iodid  of  iron,  etc.  In  the  first 
instance,  while  one  is  still  doubtful  as  to  the  existence  of  a  tubercu- 
lous deposit,  or  as  to  whether  the  disease  is  quiescent  or  active,  these 
are  the  measures  that  should  be  employed. 

When  on  a  careful  trial  of  palliative  measures  it  is  found  that  the 
enlargement  is  increasing,  and  more  especially  when  this  enlargement 
is  in  the  neighborhood  of  the  joint,  the  time  has  arrived  for  the  con- 
sideration of  operative  measures.  The  operative  measures  consist  in 
turning  aside  a  flap  so  as  to  expose  the  enlarged  portion  of  bone,  chis- 
elling through  the  hard  shell  of  the  bone,  and  cleaning  out  the  cancel- 
lous tissue  till  the  tuberculous  deposit  is  reached.  When  this  is  found, 
it  should  be  thoroughly  removed,  preferably  by  Barker's  flushing 
spoons  or  gouges.  When  the  soft  tissue  or  sequestrum  has  been 
scooped  out,  some  of  the  hard  bone  in  the  immediate  vicinity  should 
be  taken  away,  so  as  to  ensure  as  far  as  possible  the  removal  of  all  the 
tuberculous  material.  Having  thoroughly  cleared  out  the  deposit,  it 
is  well  to  sponge  the  interior  of  the  cavity  in  the  bone  with  undiluted 
carbolic  acid,  in  order,  if  possible,  to  destroy  any  tuberculous  tissue 
which  may  still  remain.  The  wound  may  then  be  stitched  up  without 
drainage.  The  carbolic  acid  does  not  seem  to  interfere  materially  with 
the  proper  formation  of  the  blood-clot.  If,  however,  there  is  much 
oozing,  it  is  well  to  introduce  at  one  angle  of  the  wound  for  two  or 
three  days  either  a  small  drainage-tube  or  a  few  strands  of  horse-hair 
or  catgut,  so  as  to  allow  the  blood  to  escape.  The  operation  must  be 
done  with  strict  aseptic  precautions,  and  an  antiseptic  dressing  applied 
afterward.  As  regards  the  subsequent  treatment,  it  is  well  to  place 
the  part  in  a  splint  for  a  time,  in  order  to  prevent  movement  and  favor 
the  organization  of  the  blood-clot.  Of  course,  the  various  constitu- 
tional means  that  have  been  mentioned  with  the  view  of  improving  the 
health  of  the  patient  should  also  be  used. 

The  treatment  is  similar  in  cases  of  tuberculous  osteomyelitis  affect- 
ing the  shafts  of  bones.  For  example,  in  strumous  dactylitis  we  should 
persevere  for  a  very  considerable  time  with  careful  rest  and  pressure 
and  good  hygienic  conditions.  Operation  is  hardly  necessary  in  these 
cases  unless  there  are  signs  of  abscess-formation  outside  the  bone. 
The  operation  consists  in  clearing  out  the  disease  and  thorough  disin- 
fection of  the  cavity  in  the  manner  just  described. 

In  the  case  of  tuberculous  osteomyelitis  of  the  small  cancellous 
bones,  such  as  the  tarsal  bones,  the  best  result  is  obtained  by  excising 
the  affected  bone  completely.  As  a  rule,  if  only  one  bone  is  taken 
away,  the  result  is  extremely  satisfactory  as  regards  the  usefulness  of 
the  foot.  In  after  years,  in  the  case  of  the  cuneiforms  more  especially, 
one  is  often  unable  to  tell  that  anything  had  been  removed  from  the 
foot. 

In  cases  where  one  cannot  remove  the  whole  of  the  tuberculous 
material  satisfactorily,  it  is  better  not  to  close  the  wound,  but  to  stuff 
it  with  gauze  sprinkled  with  iodoform,  and  to  continue  the  stuffing  of 
the  wound  till  the  whole  cavity  has  become  filled  with  healthy  granu- 
lations. When  once  this  is  the  case,  the  stuffing  may  be  abandoned, 
u 


OgO  INTERNATIONAL    TENT-BOOK  OF  SURGERY. 

the  edges  of  the  skin  refreshed  and  brought  together,  and  a  small 
drainage-tube  inserted  for  a  few  days  to  allow  the  escape  of  any  fluid. 
If  in  such  a  case  the  wound  were  stitched  up  in  the  first  instance,  the 
blood-clot  might  become  infected  with  tuberculous  material,  and  the 
disease   would   recur. 

2.  Tuberculous  Disease  of  Bone  with  Abscess. — Here  the  treat- 
ment is  practically  the  same  as  before,  with  the  exception  that  one 
should  remove  the  abscess-wall  as  thoroughly  as  possible,  and  also 
that  one  need  not  delay  at  all  witli  palliative  measures.  In  the  case 
of  tuberculous  disease  toward  the  ends  of  bone's*,  with  chronic  abscess, 
one  should  cut  down  on  the  part  and  dissect  out  the  abscess  as  if  it 
were  a  cyst,  and  then  look  for  a  hole  in  the  bone,  enlange  it  thoroughly, 
and  deal  with  the  tuberculous  deposit  in  the  interior  in  the  manner 
just  described.  In  cases  where  we  have  to  do  with  a  bone  like  the 
rib,  the  treatment  can  be  very  satisfactorily  carried  out  by  removing 
the  whole  of  the  affected  portion  of  the  bone.  In  this  case  the  surgeon 
first  separates  the  abscess  from  the  surrounding  parts  without  opening 
it,  ascertains  which  rib  is  affected  and  the  extent  of  the  disease,  divides 
the  healthy  rib  on  each  side  of  the  affected  part,  raises  it  from  the 
pleura  beneath,  and  removes  it  along  with  the  abscess.  As  the  abscess 
extends  to  the  under  surface  of  the  rib,  the  tuberculous  material  on 
the  surface  of  the  pleura  must  be  carefully  scraped  away.  The  wound 
is  then  stitched  up,  and  healing  by  first  intention  usually  occurs  with- 
out any  trouble. 

In  some  cases  the  abscess  in  connection  with  tuberculous  bone-dis- 
ease is  very  large  and  cannot  be  satisfactorily  dissected  out.  Under 
such  circumstances  one  must  lay  open  the  abscess-cavity  very  freely, 
and  dissect  away  as  much  as  possible  of  the  wall.  The  remainder 
should  be  thoroughly  scraped,  and,  if  possible,  the  deposit  in  the  bone 
sought  for  and  removed.  In  some  cases,  in  spinal  disease  for  example, 
one  cannot  carry  out  this  method  of  treatment,  and  all  that  can  be 
done  is  to  make  a  small  opening  into  the  abscess-cavity,  wash  out  the 
contents  of  the  abscess,  scrape  away  as  much  of  the  wall  as  possible, 
and  then,  the  abscess-cavity  having  been  thoroughly  cleaned  out,  in- 
ject some  sterilized  iodoform-and-glycerin  emulsion,  and  stitch  up  the 
wound.  The  result  is  usually  very  satisfactory  in  cases  where  we  have 
to  do  with  tuberculous  periostitis  ;  but  in  cases  where  there  is  a  tuber- 
culous deposit  in  the  vertebrae,  the  abscess-cavity  is  apt  to  refill.  Even 
if  it  does,  repetition  of  the  operation  on  two  or  three  occasions  will 
very  often  lead  to  satisfactory  closure  of  the  abscess,  and  if  followed  by 
suitable  fixation  of  the  spine,  to  ultimate  cure  of  the  disease. 

3.  Tuberculous  Disease  of  Bone  with  Septic  Sinuses. — We  have 
to  consider  the  cases  of  tuberculous  disease  of  bone  where  abscesses 
have  formed  and  burst,  and  where  the  patient  comes  under  observation 
with  septic  sinuses  leading  down  to  the  diseased  bone.  Here  again  the 
treatment  should  be  operative  in  the  case  of  the  extremities  and  acces- 
sible parts,  because  these  cases  with  septic  sinuses  have  but  little  ten- 
dency to  heal.  In  such  a  case  one  must  excise  the  sinuses,  expose 
freely  the  part  of  the  bone  to  which  they  lead,  and  attempt  to  remove 
the  tuberculous  portion  of  bone.  It  is  of  great  importance,  if  possible, 
to  render  the  wound  aseptic,  because  the  subsequent  progress  of  the 


SYPHILIS   OF  BONE.  69 1 

case  depends  to  a  very  great  extent  on  that  precaution.  Hence  the 
skin  should  be  thoroughly  disinfected,  and,  before  commencing  the 
operation,  it  is  well  to  scrape  away  the  granulation-tissue  at  the  orifice 
of  the  sinuses  and  to  introduce  into  it  and  leave  in  place  a  little  piece 
of  sponge  soaked  in  undiluted  carbolic  acid.  A  long  incision  is  then 
made,  sufficient  to  expose  the  part,  the  orifices  of  the  sinuses  being 
enclosed  in  elliptical  incisions.  Great  care  should  be  taken,  in  dissect- 
ing down  to  the  bone,  to  avoid  cutting  into  the  sinuses  ;  when  the  bone 
is  reached,  these  sinuses  should  be  cut  away.  The  tuberculous  deposit 
is  then  dealt  with  in  the  manner  already  described,  and  the  cavity  left 
should  be  thoroughly  sponged  out  with  undiluted  carbolic  acid.  In 
these  cases  one  can  never  be  sure  that  one  has  got  rid  of  the  sepsis,  and 
therefore  it  is  well  not  to  stitch  up  the  wound  in  the  first  instance.  It 
is  best  to  introduce  strips  of  cyanid  gauze  sprinkled  with  iodoform  into 
the  cavity  in  the  bone.  These  require  renewal  every  two  or  three  days, 
according  to  the  amount  of  discharge.  Very  soon,  if  the  tuberculous 
disease  is  completely  removed,  granulation  takes  place,  and  once  the 
whole  part  has  been  completely  covered  with  healthy  granulations,  the 
edges  of  the  skin  may  be  freshened,  detached,  and  brought  together, 
a  drainage-tube  being  left  in  at  one  end  to  allow  the  escape  of  any 
discharge. 

In  the  case  of  sinuses  leading  to  inaccessible  bones,  such  as  the 
spine,  comparatively  little  can  be  done.  Our  chief  reliance  must  be 
placed  on  good  hygienic  conditions,  on  fixation  of  the  part,  and,  if  there 
is  an  imperfect  opening,  enlargement  and  scraping  of  the  sinus.  There 
is,  however,  very  little  use  in  these  cases  in  subjecting  the  patient  to 
elaborate  operations  with  the  view  of  scraping  out  the  sinuses,  for  one 
can  seldom  get  rid  of  the  sepsis.  The  question  of  amputation, which 
arises  in  some  of  these  cases  of  bone-disease,  especially  with  septic 
sinuses,  has  chiefly  to  be  considered  in  connection  with  diseases  of 
joints. 

SYPHILIS  OF  BONE. 

Syphilitic  diseases  of  bone  may  occur  either  in  the  secondary  or  the 
tertiary  period  of  acquired  syphilis;  they«are  also  very  common  in 
inherited  syphilis.  In  the  secondary  stage  of  syphilis,  at  quite  an  early 
period  one  may  meet  with  pains  in  the  bones  without  any  enlargement 
or  apparent  lesion  of  the  bone.  These  pains  are  of  a  rheumatic  char- 
acter, sometimes  severe,  and  usually  occur  in  connection  with  the  early 
skin-eruptions.  They  probably  imply  a  merely  congestive  condition  of 
the  bone,  since  they  do  not  leave  any  permanent  lesion.  This  condi- 
tion generally  disappears  rapidly  when  the  patient  is  brought  under  the 
influence  of  mercury. 

At  a  later  period  of  syphilis,  however,  from  the  sixth  month  onward, 
one  meets  with  definite  lesions  of  the  bone,  more  especially  in  the  shape 
of  syphilitic  periostitis.  This  condition,  if  neglected,  leads  to  the  forma- 
tion of  bony  nodes.  The  bones  affected  are  chiefly  the  more  superficial 
ones,  such  as  the  skull,  especially  the  frontal  bones,  the  ribs,  the 
sternum,  the  tibia,  and  the  clavicle. 

The  Symptoms  to  which  this  condition  gives  rise  are  nocturnal  pains, 
especially  when  the  patient   gets   warm  in   bed,  and   swelling  of  the 


692  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

part  with  considerable  tenderness,  the  swelling  being  limited  in  extent, 
but  shading  off  into  the  surrounding  bone  and  not  terminating  abruptly. 
The  periosteum  becomes  thickened  ;  effusion  occurs  between  it  and  the 
bone,  leading  to  the  formation  of  a  gelatinous  material.  If  the  condi- 
tion is  not  treated,  ossification  takes  place  in  the  deeper  layers  of  the 
periosteum,  and  a  permanent  mass  of  bone  is  formed,  which  is  termed 
a  syphilitic  node.  If,  however,  the  ordinary  treatment  of  secondary 
syphilis  is  employed  at  once,  the  thickening  may  disappear  entirely. 
Hence  the  treatment  for  syphilis  (see  chapter  on  Syphilis)  should  be  at 
once  employed,  and  the  patient  should  be  quickly  brought  under  the 
influence  of  mercury.  As  regards  local  treatment,  it  is  well  to  keep  the 
part  at  rest,  and  if  there  is  much  pain  to  apply  evaporating  lotions  or 
fomentations.  Absorption  is  expedited  by  the  local  use  of  mercurial 
ointment. 

Gummatous  Disease  of  Bone. — In  the  tertiary  stage  of  syphilis 
we  meet  with  gummata  of  bone,  and  also  with  syphilitic  osteitis  accom- 
panied with  great  thickening  of  the  bone.  The  gummata  of  bone  may 
occur  subperiosteally  or  in  the  medulla,  most  usually  subperiosteally, 
and  may  form  either  circumscribed  masses  or  a  diffuse  infiltration  of 
the  bone  or  periosteum.  These  gummata  of  bone  occur  most  fre- 
quently on  superficial  bones,  such  as  the  skull,  especially  the  frontal 
bones,  where  they  begin  either  under  the  periosteum  or  in  the  diploe, 
the  clavicle,  the  tibia,  and  not  uncommonly  about  the  epiphyseal  ends 
of  bones.  The  gummatous  material  spreads  from  the  deeper  part  of 
the  periosteum  into  and  along  the  Haversian  canals,  and  leads  to  rare- 
fying osteitis  in  the  vicinity,  while  condensation  of  the  bone  takes  place 
beyond.  Hence  a  bone  which  has  been  the  seat  of  syphilitic  gumma- 
tous disease  presents  an  eroded  and  worm-eaten  appearance,  while  the 
bone  beyond  is  very  dense.  This  condition  is  sometimes  spoken  of  as 
sypliilitic  caries  of  bone,  and  great  destruction  of  bone  may  result.  In 
some  instances  portions  of  the  affected  bone  may  subsequently  die, 
and  a  sypliilitic  sequestrum  is  formed.  The  characteristic  of  a  syphilitic 
sequestrum  is  that  it  is  much  denser  than  normal  bone,  and  that  the 
surface  is  worm-eaten,  due  to  the  gummatous  material  spreading  in 
along  the  Haversian  canals  and  enlarging  them.  These  sequestra,  also, 
like  tuberculous  sequestra,  often  take  a  long  time  to  become  loose.  In 
connection  with  syphilitic  sequestra  of  bone,  there  is  not  the  same 
stalactitic  formation  of  bone  around  or  new-formation  from  the  peri- 
osteum as  in  ordinary  necrosis,  though  sometimes,  where  the  seques- 
trum is  central,  it  may'be  more  or  less  surrounded  by  bone. 

As  regards  the  symptoms  of  gummatous  disease  of  bone,  there 
may  be  a  good  deal  of  pain,  which  is  generally  more  intense  than  in 
the  case  of  the  syphilitic  node,  of  a  boring  character,  and  worse  at 
night ;  there  is  a  soft  enlargement  over  the  bone,  adherent  to  it,  and  a 
previous  history  of  syphilis.  The  gummata  do  not  remain  limited  to 
the  periosteum  of  the.  bone,  but  gradually  spread  toward  the  skin  ;  and 
ultimately  ulceration  occurs  over  them,  and  then  we  have  a  typical 
syphilitic  ulcer  of  the  skin,  with   carious  bone  at  the  bottom. 

The  treatment  of  gummatous  disease  of  bone  is  that  of  tertiary 
syphilis,  and  consists  essentially  in  the  administration  of  large  doses  of 
potassium   iodid  and   mercury;  the  potassium  iodid   must  be  given  in 


SYPHILIS   OF  BONE.  693 

large  doses,  and,  as  a  rule,  one  should  increase  the  dose  quickly  to  30 
or  40  grains  three  times  a  day.  This  is  one  of  the  forms  of  tertiary 
syphilis  in  which  surgical  intervention  for  the  purpose  of  removing  the 
diseased  bone  shortens  the  course  of  the  disease  very  much,  and  may, 
indeed,  be  the  only  means  of  obtaining  a  permanent  cure.  In  the 
case  of  syphilitic  sequestra  in  bone,  the  sequestra  remain  for  years  with- 
out any  tendency  to  separate,  in  spite  of  vigorous  antisyphilitic  treat- 
ment, and  unless  their  separation  is  expedited,  the  wound  may  never 
close.  The  surgical  intervention  consists  in  opening  up  the  part  and 
scraping  away  the  diseased  tissue,  or,  where  it  is  very  dense,  chiselling 
away  some  of  the  dense  bone.  If  a  sequestrum  is  present,  it  should, 
of  course,  be  removed.  At  the  same  time  the  constitutional  treatment 
should  be  vigorously  pushed. 

In  hereditary  syphilis  the  changes  in  bone  are  of  great  interest. 
One  of  the  earliest  is  inflammation  of  the  epiphyses  of  the  long  bones, 
more  especially  the  tibia,  the  humerus,  the  femur,  and  the  ulna.  This 
affection  is  often  symmetrical,  and  most  usually  affects  the  diaphysis  in 
the  immediate  neighborhood  of  the  epiphyseal  line,  the  condition  often 
going  by  the  name  of  "  osteochondritis."  It  generally  occurs  during 
quite  an  early  period  of  life,  and  at  the  neighborhood  of  the  epiphyseal 
line  the  bone  becomes  very  much  thickened,  and  a  tender  swelling 
appears,  forming  a  collar  around  the  end  of  the  bone  at  the  epiphyseal 
line.  This  collar  is  due  to  marked  enlargement  of  the  cartilage,  bone, 
and  periosteum  in  that  part.  In  some  cases,  where  the  disease  is 
neglected,  the  condition  may  go  on  to  separation  of  the  epiphysis  and 
destruction  of  the  epiphyseal  line. 

The  symptoms  to  which  this  condition  gives  rise  are  usually  pain 
in  the  part ;  in  fact,  what  the  mother  notices  in  the  first  instance  is  that 
the  child  does  not  seem  to  use  the  arm  at  all,  and  that  it  cries  when 
the  limb  is  moved.  On  examination  one  finds  a  collar-like  enlarge- 
ment of  the  end  of  the  bone,  very  often  symmetrical,  and  other  signs 
of  syphilis. 

During  the  first  year  of  life  also  there  is  a  tendency  in  hereditary 
syphilis  to  the  production  of  bosses  of  spongy  bone  on  the  skull, 
especially  near  the  sutures,  the  condition  sometimes  resulting  in  the  for- 
mation of  four  bosses  around  the  anterior  fontanel,  one  in  connection 
with  each  of  the  bones,  or  in  enlargements  along  the  coronal  suture, 
giving  rise  to  what  is  known  as  the  "  natiform  "  skull.  At  a  later 
period  of  hereditary  syphilis  we  have  gummatous  changes  in  the  bone, 
just  like  those  which  occur  in  adults,  destruction  of  the  nasal  bones, 
of  the  palate,  and  of  other  bones. 

As  regards  the  treatment  of  hereditary  syphilis  of  bone,  in  the 
early  stage  mercurial  treatment  is  the  best,  as  described  in  the  chapter 
on  Syphilis.  In  the  later  stages  potassium  iodid  combined  with  mer- 
cury is  the  proper  treatment. 

Phosphorus  Necrosis. — The  effect  of  phosphorus  on  the  bones  is 
often  very  marked,  the  form  of  phosphorus  which  produces  the  disease 
being  yellow  phosphorus,  not  red,  and  it  is  practically  always  the  lower 
jaw  which  is  affected.  The  result  of  the  action  of  the  phosphorus  is 
that  the  gums  become  ulcerated,  and  the  inflammatory  condition  soon 
extends  to  the  periosteum  and  the  bone.  Periostitis  sets  in,  beginning 
at  the  alveolar  margin,  and  leading  to  the  formation  of  large  spongy 


694  INTERNATIONAL    TEXT-BOOK   OE  SURGERY. 

outgrowths  from  the  bone.  Following  this  the  gum  becomes  sore  and 
more  separated,  fetid  pus  is  constantly  poured  out,  and  a  large  portion 
of  the  jaw  becomes  diseased.  Subsequently,  the  piece  of  jaw  which 
has  become  affected  may  die,  and,  in  fact,  the  whole  or  the  greater 
part  of  the  lower  jaw  may  completely  necrose.  The  phosphorus 
sequestrum,  therefore,  is  not  a  piece  of  normal  bone,  but  consists  of  the 
original  bone  with  large  spongy  osteophytic  growths  on  the  surface. 
The  condition  of  the  patient  is  a  very  serious  one,  and  he  may  die  of 
septicemia  or  pyemia. 

As  regards  the  treatment,  the  first  essential  is  to  remove  the  patient 
from  his  employment,  or  at  any  rate  to  put  him  to  work  with  red  phos- 
phorus instead  of  yellow  phosphorus.  He  should  also  be  instructed 
to  wash  his  hands  very  thoroughly  before  food,  because  it  is  probable 
that  a  good  deal  of  the  trouble  is  due  to  particles  of  phosphorus  taken 
in  with  the  food,  rather  than  to  the  vapor  of  phosphorus ;  and,  further, 
his  gums  and  teeth  should  be  carefully  watched,  and  at  the  first  sign 
of  ulceration  he  should  give  up  his  work  and  use  antiseptic  washes, 
such  as  sanitas  and  Condy's  fluid.  Where  the  disease  is  once  estab- 
lished, there  are  two  alternatives  as  regards  treatment — either  to  wait 
for  the  separation  of  the  necrosed  fragment,  or  to  excise  the  affected 
part  of  the  jaw  at  once,  leaving  as  far  as  possible  the  osteogenetic 
layer  of  the  periosteum.  The  latter  is  by  far  the  most  satisfactory 
treatment. 

RICKETS. 

Rickets  may  be  defined  as  a  disease  of  the  period  of  growth,  asso- 
ciated with  general  disturbance  of  nutrition,  and  characterized  by 
alterations  in  the  bony  tissues,  deformities  of  the  skeleton,  and  various 
internal  disorders.  Rickets  usually  occurs  during  early  life ;  but  in 
some  cases  children  are  born  with  rickets — so-called  fetal  rickets — and, 
on  the  other  hand,  the  rickety  deformities  may  not  occur  till  toward 
the  age  of  puberty. 

As  regards  the  etiology  of  rickets  many  theories  have  been  pro- 
pounded. The  two  which  seem  to  be  most  in  favor  are  that  it  is  due 
either  to  injudicious  feeding  during  infancy  or  to  imperfect  oxygenation 
of  the  blood.  Probably  both  these  views  have  a  certain  element  of 
truth  in  them.  According  to  the  first  view,  the  disease  is  more  espe- 
cially due  to  too  early  weaning  of  the  child  or  to  too  much  farinaceous 
food  during  the  first  year  of  life.  The  other  view  is  that,  as  the  result 
of  confinement  in  close  rooms,  the  blood  is  imperfectly  oxygenated, 
and  that  carbonic  acid  accumulates  in  the  blood  and  causes  the  irri- 
tating effects. 

Symptoms. — As  regards  the  effects  of  the  disease,  certain  general 
disturbances  usually  precede  the  occurrence  of  the  deformities.  The 
patient  is  subject  to  diarrhea  and  constipation  ;  the  abdomen  is  tumid 
and  sometimes  tender ;  there  is  an  excess  of  phosphates  in  the  urine, 
profuse  sweating  about  the  head,  especially  at  night  while  the  child  is 
asleep,  delayed  closure  of  the  fontanels  (which  may  not  have  com- 
pletely closed  up  even  at  two  years  of  age),  delayed  dentition,  delay 
in  walking,  great  tendency  to  bronchitis,  the  occurrence  of  laryngismus 
stridulus,  and  so  on.  From  a  surgical  point  of  view  we  have  to  do 
essentially  with  the  diseases  of  the  bones,  and  these  manifest  themselves 


RICKETS.  695 

cither  in  enlargements  about  the  epiphyseal  lines  or  in  curvature  of 
the  bones.  Enlargement  in  the  neighborhood  of  the  epiphyseal  lines 
always  occurs  to  a  greater  or  less  degree  in  rickets.  Curvature  of  the 
bones  depends  on  mechanical  causes,  and  may  not  be  marked. 

On  making  a  section  through  the  end  of  the  bone,  one  sees  that  in- 
stead of  the  two  sides  of  the  epiphyseal  cartilage  being  parallel  to  each 
other,  that  next  the  diaphysis  is  quite  irregular,  there  are  islets  of  carti- 
lage extending  into  the  bone,  the  epiphyseal  line  is  very  much  thickened, 
and  the  ossification  is  very  irregular.  The  result  is  that  at  the  epiphyseal 
lines  one  can  feel  a  distinct  enlargement,  and  this  is  especially  marked  in 
such  bones  as  the  radius,  the  lower  end  of  the  tibia,  the  ribs,  etc. ;  various 
bones  are  also  altered  in  shape.  For  example,  the  head  of  a  rickety  pa- 
tient is  generally  larger,  higher,  and  narrower  anteroposteriorly  than 
normal ;  or  it  may  be  flattened  laterally  and  elongated  anteroposteriorly. 
The  frontal  and  parietal  bones  are  enlarged ;  the  sutures  and  fontanels 
are  slow  in  closing;  the  skull  may  be  soft  and  parchment-like — a  con- 
dition known  as  "  craniotabes."  Dentition  is  delayed  for  as  much  as  six 
months  or  a  year;  the  teeth  may  be  irregular  and  imperfect;  the  hard 
palate  is  much  arched ;  the  alveolar  border  of  the  upper  jaw  is  thrown 
forward,  that  of  the  lower  jaw  inward,  and  consequently  the  teeth  do 
not  meet.  In  the  thorax  enlargements  are  found  along  the  line  of 
junction  of  the  costal  cartilage  and  the  ribs,  forming  the  so-called 
rickety  rosary;  and  in  cases  where  there  has  been  any  obstruction  to 
expiration,  as  in  children  who  have  suffered  from  bronchitis  or  broncho- 
pneumonia, there  is  generally  the  deformity  known  as  pigeon-breast. 
The  sternum  stands  forward,  the  cartilages  run  forward  toward  the 
sternum,  and  at  the  point  of  juncture  of  the  ribs  and  cartilages  there 
is  a  deep  groove.  In  rickets  also  the  chest  may  be  constricted  trans- 
versely, the  lower  ribs  being  turned  outward — attributed  by  some  to 
increased  size  in  the  abdominal  contents,  such  as  flatulent  distention  of 
the  intestines,  enlargement  of  the  liver  and  spleen,  etc.  The  spine  is 
not  uncommonly  curved,  usually  a  general  anteroposterior  curvature, 
although  in  some  cases,  in  older  children,  the  curvature  may  be  lateral. 
The  pelvis  may  be  flattened  anteroposteriorly,  or  the  acetabular  por- 
tions may  be  pushed  in  and  the  pelvis  assume  the  shape  of  an  ace  of 
hearts.  Very  often  it  does  not  develop  properly,  and  remains  small 
through  life.  The  bones  of  the  extremities  become  enlarged  at  the 
epiphyseal  lines,  and  in  addition  there  is  also  a  certain  amount  of  bend- 
ing of  the  bone,  the  natural  curves  being  increased  if  the  patient  bears 
weight  on  the  soft  bones.  The  femur  becomes  curved  anteroposteri- 
orly, and  the  tibia  most  commonly  flattened  laterally  and  curved  out- 
ward. Genu  valgum  is  also  not  uncommon  in  rickets,  and  is  frequently 
met  with  in  adolescent  rickets.  Further,  the  rickety  bones  are  very 
soft,  and  are  very  liable  to  undergo  green-stick  fracture. 

The  changes  in  the  bones  consist  essentially  in  excessive  preparation  for  the  formation 
of  new  bone  and  imperfect  deposit  of  the  hard  bony  structure.  Hence,  in  addition  to  the 
changes  in  the  epiphyseal  line  already  noticed,  the  periosteum  is  very  much  thickened,  and 
the  soft  tissue  in  the  Haversian  canals  and  lining  the  medullary  spaces  is  also  greatly 
increased  in  amount.  Thus  the  amount  of  dense  bone  is  less  than  normal,  and  the  bones 
are  soft  and  easily  bent  when  subjected  to  pressure.  If  a  rickety  bone  in  the  acute  stage  of 
rickets  is  macerated,  it  presents  a  worm-eaten  appearance  on  the  surface,  due  to  the  enlarge- 
ment of  the  Haversian  canals.  When  the  condition  of  rickets  passes  off,  bone  is  formed  in 
connection  with  this  soft  material,  and  the  consequence  is  that  the  bones  become  much 
harder  and  denser,  and  are  sometimes  very  difficult  to  cut. 


696  INTERNATIONAL    TEXT-BOOK  01-   SURGERY. 

As  regards  the  treatment  of  rickets,  attention  should  be  paid  to 
the  feeding  of  the  child  and  to  the  hygienic  conditions.  In  the  first 
place,  farinaceous  food  should  be  avoided  during  the  first  year  of  life, 
at  any  rate  during  the  first  nine  months.  The  patient's  diet  should 
consist  entirely  of  milk — if  possible,  mother's  milk  or  that  of  a  wet 
nurse.  When  the  child  is  about  nine  months  old,  oatmeal  and  various 
prepared  foods  may  be  mixed  with  the  milk,  but  it  should  be  done 
very  carefully,  and  the  essential  diet  should  still  consist  of  milk. 
When  about  a  year  old,  one  may  begin  with  meat-juice,  an  egg  once 
or  twice  a  week,  a  little  gravy  and  potatoes,  or  gravy  and  bread.  The 
child  cannot,  of  course,  take  solid  animal  food  until  toward  the  end  of 
the  second  year.  The  patient  should  also  be  placed  under  good 
hygienic  conditions,  should  be  warmly  clad  with  flannel  next  to  the 
skin,  and  care  taken  to  avoid  catching  cold ;  it  should  be  out  in  the 
air  as  much  as  possible,  and  especially  in  the  sun,  and  if  it  can  be 
managed,  should  be  sent  to  the  sea-side  or  some  country  place.  As 
regards  drugs,  the  only  two  which  seem  to  be  of  any  special  avail  are 
cod-liver  oil  and  phosphorus.  Cod-liver,  oil  should  always  be  given  in 
cases  of  rickets,  even  although  the  children  seem  to  be  well-nourished. 
Phosphorus  is  also  very  useful,  the  dose  being  yJ^  grain,  and  it  is  con- 
veniently given  mixed  with  the  cod-liver  oil. 

If  possible,  the  patient  should  be  sent  to  the  sea-side,  and  while 
there  sea-water  baths,  or,  if  they  cannot  be  obtained,  baths  contain- 
ing sea-salt,  are  very  valuable.  The  bath  should  be  slightly  tepid, 
and  after  the  bath  friction,  especially  to  the  limbs  and  abdomen,  should 
be  employed,  and  continued  for  twenty  minutes  till  the  patient  is  in 
a  thorough  glow.  Any  complications  which  arise  must,  of  course, 
be  treated  on  the  ordinary  medical  lines,  and  need  not  be  considered 
here. 

From  the  surgical  point  of  view  we  have  especially  to  consider  the 
deformities  which  are  very  apt  to  occur  in  cases  of  rickets.  Where 
we  have  to  do  with  progressing  rickets,  the  child  should  not  be  allowed 
to  stand  or  run  about,  otherwise  deformity  of  the  lower  limbs  and 
pelvis  will  almost  certainly  occur.  If  in  the  country,  it  should  be  kept 
lying  on  a  hard  mattress,  or  still  better,  allowed  to  lie  and  play  in  a 
sunny  place  on  a  heap  of  sand.  If  the  deformity  of  the  limbs  is  only 
slight,  the  probability  is  that  the  child  will  outgrow  it  if  standing  and 
■walking  are  prevented,  and  more  especially  if  friction  of  the  affected 
limbs  is  attended  to  and  manipulations  of  the  deformity  carried  out  in 
such  a  way  as  gradually  to  unbend  the  curve. 

Where,  however,  the  curve  is  marked  before  the  patient  comes 
under  the  notice  of  the  surgeon,  we  have  to  consider  the  question 
either  of  the  application  of  splints  or  of  osteotomy  with  the  view  of 
remedying  the  deformity.  While  the  rickets  is  progressing  and  the 
bones  are  still  soft,  the  application  of  apparatus  is  the  proper  treat- 
ment. Operation  in  such  cases  would  lead  only  to  disappointment ; 
the  deformity  would  almost  certainly  recur  when  the  child  began  to 
walk  about,  and  in  some  cases  the  bones  do  not  unite  after  the  opera- 
tion. Where,  on  the  other  hand,  the  rickets  has  passed  off,  and  we 
have  to  do  with  dense  bone,  splints  cannot  be  expected  to  exercise 
any  effect,  and  operation  must  be  considered. 


RICKETS.  697 

SCURVY  RICKETS. 

In  connection  with  rickets,  there  is  a  condition  which  must  be 
referred  to,  known  as  scurvy  rickets.  This  is  really  a  condition  of 
scurvy  occurring  in  infants,  and,  although  often  combined  with  rickets, 
is  not  necessarily  a  part  of  the  latter  disease,  so  that  in  that  respect  the 
name  is  somewhat  misleading.  The  condition  is  due  to  defective  feed- 
ing, and  probably  more  especially  to  the  employment  of  various  artificial 
infant  foods  and  also  to  prolonged  boiling  of  the  milk.  The  disease 
mainly  manifests  itself  by  subperiosteal  hemorrhages  in  the  long  bones. 
At  some  point  along  the  course  of  the  bone  a  firm  swelling  develops 
which  gradually  increases  in  extent  and  may  spread  along  the  entire 
length  of  the  shaft.  This  swelling  consists  of  blood,  which  remains 
more  or  less  fluid  and  is  extravasated  beneath  the  periosteum  and  also 
to  a  lesser  extent  among  the  deeper  muscles.  The  femur  is  most  com- 
monly affected.  Fractures  are  very  apt  to  occur,  either  spontaneously 
or  after  very  slight  manipulation  in  these  cases.  In  the  case  of  scurvy 
pure  and  simple  these  fractures  are  commonest  in  the  shafts  of  the  long 
bones  ;  while  in  the  case  of  scurvy  associated  with  rickets,  separation  of 
one  or  both  epiphyses  of  the  bone  affected  is  more  likely  to  be  met  with. 
Spongy  and  bleeding  gums  are  not  very  noticeable  in  these  cases,  but 
spontaneous  hemorrhages  are  not  uncommon.  If  the  case  be  left  un- 
treated, the  hemorrhages  increase  and  the  child  dies  from  exhaustion  or 
from  some  intercurrent  affection.  The  condition  does  not  arise  in  infants 
brought  up  on  the  breast  during  the  ordinary  period  of  lactation. 

Treatment. — If  the  child  is  not  more  than  nine  months  old,  a  wet- 
nurse  is  the  best  arrangement;  but  if  that  is  not  possible,  pure,  fresh 
cows'  milk  which  has  not  been  boiled  should  be  given,  and  artificial 
food  or  prepared  milk  absolutely  avoided.  The  juice  of  an  orange 
once  a  day  and  something  like  a  dozen  grapes  during  the  day  should 
be  added  to  the  diet.  Usually,  under  this  simple  treatment,  the  con- 
dition will  rapidly  improve,  and  in  the  course  of  two  or  three  weeks  the 
thickening  of  the  periosteum  will  have  practically  disappeared.  After 
the  age  of  nine  months  the  diet  should  still  be  mainly  milk,  but  vege- 
tables and  fruit  should  be  consistently  added  to  it. 

OSTEOMALACIA. 

This  is  a  disease  usually  occurring  in  adult  women  after  pregnancy, 
the  chief  manifestation  of  which  is  softening  of  the  bones.  In  osteo- 
malacia rarefaction  of  the  bones  takes  place,  with  loss  of  calcareous 
salts,  the  bones  in  the  first  instance  becoming  slightly  enlarged,  the 
medullary  cavity  increasing  in  size  and  containing  red  marrow,  and 
the  shell  of  the  bone  becoming  very  much  thinned  and  often  perfo- 
rated like  a  sieve.  These  bones  are  extremely  liable  to  undergo 
fracture,  and,  apart  from  fracture,  they  bend  in  a  most  extraordinary 
manner.  Associated  with  this  increasing  change  in  the  bones  is 
usually  very  severe  pain  of  a  neuralgic  character,  and  the  patient 
suffers  in  health  and  strength.  The  disease  is  an  extremely  grave 
one,  and  usually  proves  fatal  in  about  two  years  from  its  commence- 
ment, death  occurring  from  marasmus,  cachexia,  asphyxia,  or  some 
acute  affection  of  the  respiratory  organs. 


698  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

As  regards  treatment,  in  the  first  instant  the  patient  should  be 
put  under  the  best  conditions  as  regards  hygiene,  and  lately  improve- 
ment has  been  recorded  from  the  use  of  tabloids  of  bone-marrow.  As 
to  drugs,  phosphorus,  phosphoric  acid,  and  more  especially  phosphate 
of  zinc,  ^g-  or  -^  grain,  given  in  a  pill  three  times  a  day,  are  advocated, 
but  they  do  not  exercise  any  particular  effect.  If  the  patient  is  preg- 
nant, it  is  often  well  to  produce  abortion.  Some  report  good  results 
from  oophorectomy. 

OSTEITIS  DEFORMANS. 

This  is  a  rare  disease  which  occurs  after  the  age  of  forty-five  and 
affects  males  more  often  than  females.  It  begins  insidiously  or  with 
pain  and  aching  in  the  bone  ;  it  usually  commences  in  the  lower  extremi- 
ties, but  it  soon  spreads  over  the  chief  bones  of  the  skeleton.  The 
bones  become  enlarged,  heavy,  and  bent ;  the  femur  and  tibia  become 
arched  forward,  and  walking  is  difficult  from  the  weight,  deformity,  and 
muscular  weakness.  The  spinal  column  becomes  bent,  rigid,  and  thick- 
ened. There  is  loss  of  height,  the  hands  hang  lower  than  usual,  the 
shoulders  are  rounded,  the  head  projects  forward,  the  chin  is  raised,  and 
the  chest  is  sunk  on  the  pelvis.  On  making  sections  of  the  bones  they 
are  found  to  be  much  thickened  and  cancellous.  The  change  consists 
in  absorption  of  the  dense  bone  and  rarefying  osteitis,  resulting  in  parts 
in  the  formation  of  large  and  irregular  Haversian  canals,  while  in  other 
parts  formative  processes  are  going  on.  The  cause  of  the  trouble  is 
not  known. 

As  regards  the  prognosis,  the  disease  usually  steadily  progresses 
in  spite  of  any  treatment,  and  it  may  go  on  for  years  ;  ultimately  the 
patient  dies  from  exhaustion,  although  in  some  cases  death  may  occur 
from  the  development  of  malignant  tumors  in  connection  with  the 
bone. 

The  treatment  is  practically  nil.  The  patient  is  generally  put  on 
a  milk  diet,  alkalies  given,  tabloids  of  bone-marrow  or  thyroid  extract 
may  be  administered,  and  he  is  placed  under  the  best  hygienic  condi- 
tions. Massage  is  employed  with  the  view  of  keeping  the  muscles  in 
vigor,  but  nothing  seems  to  have  any  real  power  in  arresting  the  disease. 

ACROMEGALY. 

This  disease  generally  commences  between  the  ages  of  fifteen  and 
thirty-five,  and  consists  in  enlargement  of  the  hands  and  forearms,  the 
feet,  the  jaw,  and  sometimes  of  other  bones.  It  is  accompanied  by 
mental  slowness  and  very  often  imbecility,  wasting  of  muscles,  exag- 
geration or  loss  of  reflexes,  and  increasing  weakness.  The  bones  are 
more  porous  than  usual.  The  cause  is  unknown  ;  the  pituitary  body 
has  been  found  enlarged  in  several  cases.  Many  giants  are  acromegalic. 
The  patients  usually  die  comparatively  young,  of  phthisis  or  some 
infective  disease ;  their  resisting  power  is  very  slight. 

The  treatment  is  absolutely  nil.  Tabloids  of  thyroid  extract  or 
of  pituitary  body  are  usually  prescribed. 

LEONTIASIS  OSSIUM. 

This  is  a  disease  which  is  characterized  by  the  occurrence  of  marked 
outgrowths  on  the  upper  jaw,  and  sometimes  on  the  skull.     These  out- 


TUMORS   OF  BOXE.  699 

growths  consist  of  masses  of  spongy  bone  which  may  fill  up  the  antrum, 
the  nasal  cavity,  and  the  orbit,  or  press  upward  against  the  base  of  the 
skull,  causing  serious  effects  from  the  pressure — for  example,  in  the 
case  of  the  orbit  leading  to  atrophy  of  the  optic  nerve,  and  ultimately 
to  blindness.  Very  frequently  the  patient  dies  as  the  result  of  intra- 
cranial pressure.  Here  again  the  etiology  of  the  disease  is  unknown, 
and  there  is  practically  no  remedy.  In  some  cases  the  bosses  in  the 
upper  jaw  may  be  chiselled  away  if  they  are  found  to  be  projecting 
into  the  orbit,  or  portions  may  be  removed  which  are  pressing  on  the 
base  of  the  skull ;  but  the  disease  recurs  almost  immediately. 

TUMORS  OF  BONE. 

Many  tumors  occur  in  bone,  either  developing  primarily  in  the  bone, 
or  as  secondary  tumors  in  connection  with  growths  in  distant  parts,  or 
again  from  involvement  of  the  bone  in  tumors  commencing  in  the  soft 
parts  in  the  neighborhood. 

The  primary  tumors  of  bone  are  chiefly  exostoses,  chondromata, 
and  various  forms  of  sarcomata.  The  secondary  tumors  are  sarcomata 
and  carcinomata.  Hyatid  cysts  are  also  said  to  occur  in  bones.  The 
treatment  of  tumors  of  bone  depends  on  the  nature  of  the  tumor  and 
the  bone  affected. 

The  exostoses  of  bones  occur  in  two  forms:  the  sessile  exostoses, 
which  are  chiefly  found  on  the  skull,  and  the  spongy  exostoses,  which 
occur  generally  about  the  neighborhood  of  the  epiphyseal  lines  of 
bones.  The  spongy  exostoses  may  be  multiple,  and  may  interfere  very 
much  with  the  movements  of  the  joint  or  the  muscles  in  the  neighbor- 
hood. The\-  are  hard  and  knobby  on  the  surface,  and  are  firmly 
attached  to  the  bone  in  the  neighborhood  of  the  joints.  They  are 
composed  of  cancellous  bone,  and  grow  at  the  surface  from  a  layer  of 
cartilage  which  covers  them.  This  cartilage  very  soon  completely 
ossifies  at  the  point  where  the  exostosis  is  attached  to  the  bone,  and 
thus  growth  ceases  at  that  point,  whereas  it  continues  in  all  directions 
on  the  surface,  giving  rise  to  the  overhanging  character  of  the  tumor, 
so  that  a  tumor  which  may  be  in  reality  very  large  may  have  only  a 
very  narrow  neck  of  junction  with  the  bone. 

The  treatment  of  these  exostoses  is  removal  wherever  they  are 
causing  any  trouble.  If  the  operation  is  done  antiseptically,  it  is  free 
from  danger.  The  operation  consists  in  making  an  incision  toward  one 
side  of  the  tumor,  so  as  to  get  at  the  neck,  exposing  the  point  of  attach- 
ment to  the  bone,  and,  after  clearing  it,  chiselling  it  across  close  to  the 
bone.  The  exostosis  can  then  usually  be  shelled  out  of  the  tissue  in 
which  it  is  lying  without  any  trouble.  If  it  has  involved  any  tendon  or 
nerve  in  the  overhanging  processes,  these  must  be  carefully  cleared. 
Asepsis  is  imperative. 

The  sessile  or  ivory  exostoses  are  composed  of  dense  bone  usually 
showing  only  lacunae  and  canaliculi,  but  no  Haversian  canals.  They 
seldom  attain  any  great  size,  and  are  generally  found  on  the  skull. 
Beyond  producing  a  little  deformity,  they  do  not,  as  a  rule,  cause  any 
trouble  to  the  patient,  and  therefore  their  removal  is  seldom  called  for 
unless  as  a  matter  of  personal  appearance.  The  operation  is  not  alto- 
gether free  from  risk.     The  exostoses  themselves  are  extremely  dense, 


700  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

and  considerable  force  is  required  to  chip  them  off,  so  that  in  exercising 
the  necessary  amount  of  force  in  the  case  of  the  skull  one  may  produce 
a  fissured  fracture.  Where  the  exostosis  is  small,  a  large  trephine  may 
be  placed  over  and  including  the  exostosis,  and  the  whole  thickness  of 
the  skull,  or  at  any  rate  the  outer  table,  removed ;  but,  as  a  rule,  unless 
under  special  circumstances,  where  they  are  causing  pressure  on  nerves, 
or  where  they  are  growing  into  the  orbit  or  pressing  on  the  brain,  they 
are  better  left  alone. 

Chondromata. — These  are  also  common  tumors  of  bones,  and 
they  most  frequently  occur  in  connection  with  the  phalanges  or  meta- 
carpal bones.  They  are  usually  multiple,  and  may  grow  either  from 
the  outside  of  the  bone  or  in  the  interior.  They  are  usually  benign. 
The  chondromata,  on  the  other  hand,  may  give  rise  to  very  remarkable 
deformity  from  the  presence  of  multiple  tumors  in  connection  with  the 
bones,  and  may  interfere  very  seriously  with  the  usefulness  of  the  hand 
from  pressure  on  the  tendons,  interference  with  movements  of  joints, 
etc.  The  tumors  are  generally  smooth,  often  knobby  and  somewhat 
elastic. 

Treatment. — In  most  cases  it  is  advisable  to  remove  these  enchon- 
dromata  in  the  early  stage,  because  they  usually  go  on  growing  and 
attain  a  size  which  ultimately  interferes  with  the  movements  of  the 
part.  In  removing  them  it  is  usually  sufficient  to  cut  down  on  the 
tumor,  chisel  away  the  projecting  portion,  and  then  thoroughly  gouge 
away  any  deposits  of  cartilage  which  may  be  present  in  the  neighbor- 
hood. If  they  are  growing  in  the  interior  of  the  bone,  one  must  chisel 
through  the  shell  of  the  bone  and  scoop  out  the  soft  enchondroma- 
tous  material  from  the  interior.  It  is  seldom  necessary  to  amputate 
a  finger  or  to  remove  a  metacarpal  bone  on  account  of  these  enchon- 
dromata.  In  some  cases  these  enchondromata  do  not  appear  to  be 
quite  simple,  and  where  there  is  a  suspicion  of  any  malignant  character 
about  the  growth,  it  is  better  to  amputate  if  possible ;  but,  as  a  rule, 
these  semi-malignant  enchondromata  are  not  those  which  occur  on  the 
hands  or  feet.  They  are  usually  those  which  occur  about  the  pelvis 
and  other  parts,  where  their  removal  is  not  possible,  and  the  probability 
isthat  they  are  a  combination  of  sarcoma  and  chondroma. 

Sarcomata  of  bone  may  be  of  various  kinds.  Perhaps  the  most 
common  is  the  osteosarcoma  or  periosteal  sarcoma,  which  begins  in  the 
periosteum  of  the  bones  and  spreads  along  the  periosteum  for  a  veiy 
considerable  distance.  These  tumors  usually  show  very  imperfect  ossi- 
fication, and  the  secondary  tumors  occurring  in  the  lungs  and  elsewhere 
generally  show  the  same.  This  is  a  very  malignant  form  of  sarcoma, 
and  the  chances  of  rescuing  the  patient  by  operation  are  very  small. 
Nevertheless,  one  should  give  the  patient  a  chance,  and  the  best  pros- 
pect is  in  amputation  wide  of  the  disease.  In  these  cases  of  periosteal 
sarcoma  no  attempt  should  be  made  to  save  any  portion  of  the  affected 
bone  ;  the  operation  must  be  performed  through  or  above  the  neighbor- 
ing joint.  Unfortunately,  however,  metastatic  deposits  occur  very  early 
in  these  cases,  affecting  the  glands  and  the  lungs,  and  the  great  major- 
ity of  these  cases  of  osteosarcomata  recur  after  removal.  The  bone 
most  frequently  affected  is  the  femur.  The  disease  gives  rise  to  en- 
largement generally  at  the  lower  end  of  the  femur,  usually  more  or 
less  unilateral,  extending  upward  along  the  shaft  of  the  femur. 


/'(MORS    OF  BOX/;'.  701 

5pindle=celled  sarcomata  also  occur  in  connection  with  the  perios- 
teum of  bones,  giving  rise  to  tumors  not  readily  distinguishable  from 
the  osteosarcomata  just  referred  to.  In  this  case  also  amputation 
through  the  bone  or  joint  above  is  the  best  practice. 

Round=celled  sarcoma  also  occurs  in  connection  with  bones,  and 
it  very  often  grows  in  the  interior,  perhaps  the  most  common  seat 
being  the  head  of  the  humerus.  Here  we  have  to  deal  with  a  very 
malignant  tumor.  In  these  cases  of  round-celled  sarcomata  there  is 
marked  enlargement  of  the  bone,  and  the  tumor  is  soft  in  consistence 
where  it  has  burst  through  the  shell  of  the  bone.  One  point  of  impor- 
tance is  that  it  very  seldom  destroys  the  articular  cartilage  and  spreads 
into  the  joint.  Where  it  spreads  on  to  a  neighboring  bone,  it  is  by 
bursting  through  the  shell  of  the  bone  beyond  the  articular  cartilage 
and  spreading  in  the  ligaments  of  the  joint.  This  should  be  very  care- 
fully borne  in  mind,  and,  as  a  matter  of  fact,  in  amputation  of  the  upper 
arm  for  round-celled  sarcoma  of  the  humerus,  for  example,  the  liga- 
ments of  the  joint  and  the  articular  surface  of  the  scapula  should  also 
be  removed. 

Myeloid  sarcoma  grows  especially  about  the  lower  end  of  the  femur, 
the  lower  end  of  the  tibia,  and  the  lower  jaw.  This  is  the  least  malig- 
nant of  all  the  forms  of  sarcomata;  in  fact,  it  is  a  question  whether  it 
should  be  included  in  that  group  at  all.  Growing  in  the  situations  men- 
tioned, it  usually  commences  in  the  interior  of  the  bone,  and  leads  to 
expansion  of  the  end  of  the  bone,  which  after  a  time  becomes  more  or 
less  one-sided.  Ultimately  it  perforates  the  bone  and  extends  in  the 
soft  tissues.  It  forms  there  a  fairly  well-limited  soft  swelling  on  the 
side  of  the  bone,  often  cystic  in  character.  On  section,  a  myeloid  sar- 
coma is  of  a  chocolate  color,  and  usually  contains  numerous  cysts  in 
the  interior,  as  the  result  of  mucous  degeneration  commencing  in  con- 
nection with  the  large  myeloid  cells. 

As  regards  treatment,  on  account  of  the  lesser  degree  of  malignity, 
it  is  not  necessary  to  treat  the  cases  so  thoroughly  as  in  the  other  forms 
of  sarcoma ;  in  fact,  in  a  considerable  number  of  cases  the  myeloid 
tumor  may  be  simply  scraped  away.  If  this  is  done,  it  must  be  done 
very  thoroughly,  and  one  must  be  quite  sure  that  all  the  growth  has 
been  removed,  otherwise,  of  course,  it  will  recur.  Apparently,  how- 
ever, it  does  not  spread  and  infiltrate  the  tissues  to  any  great  extent,  so 
that  very  little  tissue  need  be  removed  beyond  the  actual  tumor  itself. 
Sometimes,  where  a  myeloid  sarcoma  has  been  in  existence  for  some 
time,  this  is  not  feasible,  because  no  solid  bone  is  left  behind,  and  in 
these  cases  it  is  necessary  to  amputate.  Amputation  even  then  need 
only  be  done  through  the  bone  a  short  distance  above  the  tumor. 

Malignant  tumors  also  occur  in  bones  secondarily  to  epithelio- 
mata,  carcinomata,  or  sarcomata  elsewhere,  and  they  lead  to  the  forma- 
tion of  tumors  presenting  all  the  malignant  characters,  and  in  the  case 
of  carcinomata  usually  accompanied  with  very  intense  neuralgic  pain. 

As  regards  treatment,  no  attempt  need  be  made  to  remove  them, 
as  they  indicate  extensive  infection  of  the  system,  the  treatment  con- 
sisting in  steadying  the  part  in  cases  where  the  tumor  has  so  eroded 
the  bone  that  it  has  given  way,  and  in  taking  measures  to  relieve  the 
pain  as  far  as  possible. 


CHAPTER    XX. 
DISEASES  OF  THE  JOINTS. 

SYNOVITIS. 

Synovitis  is  an  inflammatory  condition  of  the  serous  lining  of  a 
joint. 

Pathology. — The  clinical  term  "  inflammation  "  expresses  most 
definitely  to  the  average  professional  mind  the  phenomena  resulting 
from  the  contusion  of  a  joint  or  incited  by  the  entrance  of  a  foreign 
body.  The  process  may  be  simply  a  histologically  regenerative  one 
without  the  presence  of  bacteria,  or  it  may  advance  to  a  destructive 
condition  where  the  micro-organisms  are  specific  in  character. 

Inflammation  embraces  the  pathological  conditions  which  are  the 
effect  of  these  organisms  upon  histological  elements  contained  in  the 
blood  or  in  the  tissue-cells.  An  excellent  definition  of  this  process  is 
"  the  phagocytic  method  by  which  an  organism  attempts  to  render 
inert  noxious  elements  introduced  from  without  or  arising  from  within." 
The  stages  of  hyperemia,  congestion,  stasis,  exudation,  emigration  of 
wandering  cells  or  of  red  cells  (diapedesis),  are  essential  elements  in  this 
phagocytic  process.  It  is  not  the  migrated  .cells  that  chiefly  produce 
new  tissue,  but  the  increased  functional  activity  of  the  fixed  tissue-cells 
due  to  the  presence  of  this  exuded  element. 

Resistive  power  being  vigorous,  the  circulation  may  be  restored, 
resorption  occur,  and  speedy  cure  follow.  It  is  argued  by  some  authors 
that  this  process  should  not  be  classed  as  an  inflammation,  since  micro- 
organisms are  not  concerned.  Should  the  resistive  power,  however,  be 
less  positive,  or  the  traumatism  more  severe,  micro-organisms  gain 
access,  and  the  infection,  added  to  congestion  and  exudation,  will  result 
in  emigration  of  leukocytes  and  other  cells,  phagocytic  conflict,  and  the 
resultant  debris  of  destructive  action — pus. 

Contusions,  sprains,  or  any  form  of  traumatism,  direct  or  indirect, 
may  be  productive  of  a  hyperemia  followed  by  the  ordinary  phenomena 
of  an  inflammatory  process,  with  loss  of  function  and  increased  exudate 
of  normal  joint-fluid,  or,  in  further  continuance  of  the  process,  by 
fibrinous  exudate.  Should  the  articulation  become  infected  by  pyo- 
genic cocci,  either  from  without  or  from  within,  suppuration  will  follow, 
with  destruction  of  the  cartilage;  or  the  process  may  advance  to  bone- 
disease,  a  condition  which  will  be  described  under  Arthritis. 

Flexion  is  favored  by  distention  and  by  muscular  contraction  in  the 
attempt  to  place  the  joint  at  rest.  In  the  slow  or  chronic  variety  the 
distention  may  increase  very  gradually  and  be  unaccompanied  by  any 
of  the  ordinary  symptoms  enumerated.     In  certain  joints,  as  in  the 

702 


SYNOVITIS. 


703 


knee,  where  the  area  of  synovial  membrane  is  large,  the  amount  of 
fluid  present  is  sometimes  great.  The  ramifications  of  the  membrane 
beneath  and  above  the  patella  and  the  bursa  beneath  the  quadriceps  are 
seriously  involved  in  the  process. 

The  effect  of  rapid  exudation  of  serum  following  a  severe  injury  of 
the  knee  is  well  illustrated  in  the  accompanying  cut,  in  which  the 
sudden  increase  of  fluid  in  the  bursa  above  and  below  the  patella  gives 


Fig.  343. — Synovial  effusion  simulating  fractured  patella. 


the  appearance  of  a  fracture  of  the  bone  with  separation  of  fragments 

(Fig.  343)- 

Rheumatism,  acute  fevers,  infectious  processes  of  micro-organisms, 
etc.,  are  also  among  the  causes  of  synovitis,  and  will  be  further  consid- 
ered under  special  headings. 

Diagnosis. — The  diagnosis  will  depend  upon  the  history  of  trau- 
matism, and  the  differentiation  of  acute  symptoms  from  those  of  rheu- 
matic, septic,  or  other  origin. 

Treatment. — The  essential  element  of  treatment  is  rest  of  the 
affected  joint.  This  is  accomplished  by  the  removal  of  weight-bearing, 
by  fixation  of  the  articulation  with  some  form  of  splint,  the  application 
of  ice-bags  or  of  the  ice-coil,  and  local  evaporating  lotions  of  witch 
hazel,  tincture  of  opium,  or  astringents.  The  employment  of  hot 
douching  for  an  hour  following  the  reception  of  a  sprain  will  frequently 
greatly  lessen  not  only  the  pain  but  the  resultant  effects.  This  process 
may  be  repeated  with  advantage  once  or  twice  during  the  first  twenty- 
four  hours  following  an  injury.  Absolute  rest,  by  arresting  hyperemia 
and  subsequent  inflammation,  guards  against  resultant  ankylosis.  The 
more  complete  the  enforcement  of  rest,  the  more  certain  will  be  the 
abortive  effects ;  consequently  confinement  to  bed  or  the  employment 
of  crutches  and  splints   is  of  the  greatest  importance. 

Splints  of  wood,  felt,  tin,  silicate,  or  plaster  of  Paris  are  especially 
helpful  by  resisting  muscular  action  and  preventing  even  the  slightest 


704  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

movement  of  the  joint.  The  splint  cannot  be  applied  too  early,  as  an 
abortion  of  the  process  will  often  save  weeks  or  months  of  disability  or 
disease,  and  effusion  often  takes  place  within  a  few  hours  after  the 
injury. 

Serous  effusion  may  be  treated  by  local  counterirritants,  blisters, 
pressure  with  compressed  sponge,  or  by  aseptic  aspiration.  Aspiration, 
if  cleanly  performed,  should  be  employed  early  in  order  to  promote 
speedy  recovery  of  circulation  in  the  compressed  serous  membrane. 
Adhesive-plaster  strapping  will  greatly  assist  in  absorption  of  fluid  and 
in  giving  uniform  support  to  a  joint,  and  is  preferable  to  an  ordinary 
bandage.  When  applied  to  the  entire  convexity  of  a  joint  it  greatly 
limits  motion. 

Suppurative  synovitis  should  be  tested  with  an  aspirator,  and  if 
streptococci  are  present,  incision  with  irrigation,  and  drainage  if  neces- 
sary, should  be  practised. 

Septic  synovitis  occurring  in  the  course  of  an  acute  septic  condition 
has  its  origin  from  toxic  elements  in  the  blood,  and  suppuration  is  the 
rule  ;  consequently  early  incision  with  cleansing  is  essential.  Caution, 
however,  should  be  exercised  in  irrigating  a  joint.  Simple  sterile  water 
or  salt  solution  are  best,  but  weak  solutions  of  bichlorid  (i  :  10,000), 
chlorid  of  zinc  (i  :  5000),  or  formaldehyd  (1  :  1000)  maybe  employed. 

ARTHRITIS. 

Arthritis,  or  acute  articular  osteitis,  is  an  inflammatory  condition  of 
the  joint-structures,  involving  both  synovial  membrane  and  the  sur- 
rounding hard  and  soft  tissues. 

Ktiology. — The  forms  of  arthritis  are  classified  chiefly  according 
to  their  causes,  as  traumatic,  rheumatic,  gonorrheal,  tubercular,  febrile, 
etc.,  which  will  be  considered   under  their  special  headings. 

Symptoms. — Arthritis  may  commence  as  a  synovitis,  extension 
occurring  from  the  synovial  membrane  to  the  cartilage,  thence  to  the 
bone-structures  ;  or  the  process  may  advance  from  the  bone  toward 
the  articulation,  as  in  tubercular  osteomyelitis.  The  process  is  ordi- 
narily less  acute  than  in  synovitis  ;  the  pain  is  intense,  while  the  exuda- 
tion into  the  tissues  about  the  joint  will  vary  with  the  causative  disease. 
Flexion  is  the  rule,  and  night-cries  are  common,  from  the  impingement 
of  the  inflamed  surfaces. 

In  simple  traumatic  arthritis  without  a  septic  cause,  the  symptoms 
will  at  first  be  similar  to  those  described  under  Synovitis ;  but  the 
steady  extension  to  the  surrounding  structures  soon  gives  evidence  of 
a  wider  area  of  involvement,  even  to  bony  structure.  Pain  is  usually 
severe  ;  redness,  heat,  and  swelling  are  more  marked,  and  infection  from 
staphylococci  and  streptococci  is  rapid.  In  the  chronic  forms  of  tuber- 
cular and  rheumatoid  arthritis  the  symptoms  are  slow  and  insidious, 
and  their  recognition  is  more  difficult. 

Acute  suppurative  arthritis,  ending  in  complete  ankylosis,  often 
arises  from  punctured  septic  wounds.  The  skiagraph  exhibits  a  non- 
suppurative punctured  wound  in  childhood  resulting  in  ankylosis  so 
absolute  that  the  cancellated  tissue  of  the  femur  and  that  of  the  tibia 
appear  in  adult  life  to  be  absolutely  continuous  (Fig.  344). 


ARTHRITIS. 


705 


Pathology. — In  simple  arthritis  the  process  is  primarily  one  of  hyperemia,  as  described 
under  Synovitis,  the  condition  being  accompanied  early  by  the  exudation  of  cell-elements 
into  the  surrounding  tissues.  Should  this  exudate  degenerate,  either  from  infection  by 
pyogenic  cocci  or  from  external  causes,  suppuration  will  follow,  with  the  loss  of  bone-sub- 
stance. In  septic,  gonorrheal,  and  similar  infections  suppuration  may  take  place  in  a  few 
hours. 

Diagnosis. — The  diagnosis  of  the  existence  of  arthritis  is  not  dif- 
ficult,  but  the   discovery   of  the   cause  will   include   a   review  of  the 


FlG.  344. — -Total  obliteration  of  the  knee-joint,  with  fusion  of  femur  and  tibia. 


entire  history  and  progress  of  the  disease  with  all  its  attendant  symp- 
toms. The  stealthy  advance  of  a  tubercular  process  in  a  joint  where 
resistive  power  has  been  temporarily  reduced  by  an  injury  is  so 
frequent  that  its  occurrence  should  always  be  suspected.  Induration, 
doughy  in  character,  especially  when  situated  over  the  neighboring 
bone-areas  rather  than  directly  about  the  articulation,  should  at  once 
arouse  suspicion  of  tuberculosis. 

Rheumatic  and  gouty  arthritis  are  usually  accompanied  by  fever 
and  other  constitutional  symptoms,  and  several  joints  are  liable  to  be 
infected.  In  rheumatoid  or  dry  arthritis  the  onset  is  slow,  creaking 
is  often  distinct,  and  nodosities  are  common. 

45 


706  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Bursa;  about  the  knee,  when  chronically  inflamed,  will  give  to  the 
surgeon  the  sensation  of  a  localized  soft  fluctuating  tumor,  and  will  be 
accompanied  with  lameness  and  tenderness.  Flexion  is  usually  absent, 
or  not  so  marked  as  in  joint-inflammation. 

The  prognosis  will  necessarily  depend  upon  the  severity  of  the 
process  and  the  character  of  the  infection. 

Treatment. — The  treatment  will  include  the  removal  of  the 
exciting  cause,  and  the  control  of  the  condition  as  indicated  under  the 
special  forms  of  arthritis.  Rest  should  primarily  be  thoroughly  enforced 
in  bed,  or  later  upon  crutches  in  the  open  air,  provided  the  lower  limb 
be  the  one  affected.  Weight-and-pulley  extension  is  often  of  service. 
Splints  of  wood  or  plaster  are  of  absolute  importance.  Locally,  iodin, 
blisters,  absorbent  liniments,  mercury,  belladonna,  etc.  are  helpful. 
Internally,  potassium  iodid,  arsenic,  iron,  cod-liver  oil,  etc.  are  indi- 
cated. Surgically,  in  all  the  suppurative  forms,  early  incision,  washing, 
and  drainage  are  essential.  Erasion  and  excision  may  become  neces- 
sary, and  amputation  must  be  practised  in  special  cases. 

Acute  Gouty  Arthritis. — Acute  gouty  arthritis  is  a  form  of  joint- 
inflammation  due  to  perverted  nutrition  and  the  accumulation  of  uric 
acid  salts  in  the  blood,  producing  deposits  of  sodium  urate,  etc., 
especially  in  the  smaller  articulations. 

Etiology. — Gout  is  a  disease  in  which  the  income  of  nutrition  is 
greater  than  the  outgo  of  waste.  Limited  excretion  and  the  accumu- 
lation of  uric  acid,  producing  derangement  of  nutrition,  are  recognized 
factors.  Both  defective  oxidation  and  defective  elimination  are  present. 
Active  cell-proliferation  probably  causes  the  primary  disturbance,  while 
the  deposits  are  secondary. 

Heredity  plays  a  most  important  part  in  the  production  of  this  dis- 
ease. The  special  originating  causes  are  excesses,  especially  in  the  use 
of  alcoholic  liquors  and  the  heavier  wines  and  in  food-supply,  although 
it  is  erroneous  to  assume  that  this  disease  is  necessarily  one  of  luxury. 
A  deficient  amount  of  food  and  lack  of  air  and  sunshine  are  also  fre- 
quent causes. 

The  smaller  articulations  suffer  more  than  the  larger  ones,  and 
various  manifestations  of  poison  are  found  in  the  throat,  head,  eyes, 
and  all  portions  of  the   body. 

The  acute  variety  is  sudden  in  its  onset  and  accompanied  by  the 
most  excruciating  pain,  with  other  inflammatory  symptoms  in  the 
smaller  joints.  Its  exacerbations  are  most  severe  at  night.  I  have 
seen  violent  attacks  occurring  in  one  night,  following  an  excessive  use 
of  champagne,  with  inflammatory  symptoms  sufficiently  severe  to  end 
in  suppuration  of  a  knee. 

Treatment. — The  cure  of  gouty  arthritis  consists  in  the  elimination 
of  the  cause  and  the  combating  of  the  articular  inflammation.  The 
most  hopeful  aids  are  alkaline  waters,  diuretics,  diaphoretics,  and 
cathartics,  with  abundant  fluids.  Local  anodyne  applications  relieve 
pain.  Superheated  hot  air  (see  p.  707)  is  useful,  as  it  assists  in  the 
absorption  of  the  uric-acid  deposit.  Care  must  be  taken,  however, 
when  this  treatment  is  employed,  that  the  products  thus  scattered  shall 
not  be  retained  in  the  system,  but  that  they  shall  be  flushed  out  either 
through  the  kidneys,  or  intestines,  or  skin.     Operative  interference  will 


ARTHRITIS.  JOJ 

be  called  for  in  cases  of  joint-suppuration.  In  such  cases  the  treatment 
will  be  washing  and  drainage  as  in  ordinary  suppurative  arthritis. 

Acute  Rheumatic  Arthritis. — Rheumatic  arthritis  is  an  inflam- 
matory condition  of  a  joint  produced  by  a  special  poison,  probably 
chemical,  but  possibly  a  saprophytic  organism  acting  upon  the  fibrous 
tissues. 

Etiology  and  Symptoms. — Various  organisms  are  claimed  to  be 
quite  persistently  present,  a  delicate  diplococcus  differing  from  that  of 
pneumonia,  the  various  streptococci,  the  staphylococci,  etc.,  but  their 
causative  effect  is  not  yet  definitely  fixed. 

Achaline,1  from  researches  on  both  dead  and  living  bodies,  claims  to  have  discovered  an 
abundance  of  rod-shaped  aerobic  bacilli  in  a  state  of  pure  culture  in  the  normal  fluids, 
myocardium,  and  diseased  valves  of  the  heart.  Biologically  the  bacillus  is  peculiar  in  that 
its  culture  gives  rise  to  the  production  of  lactic  and  other  acids.  Inoculation  gives  charac- 
teristic lesions,  and  guinea-pig  inoculation-serum  gives  rise  to  lesions  of  endocardium  and 
pleura.  Triboulet  and  Cayon  -  also  claim  to  have  isolated  the  diplococcus.  A  joint  synovial 
membrane,  being  excessively  vascular,  may  readily  receive  either  microbes  or  toxins  directly 
from  the  vessels. 

Lithemia,  a  condition  of  defective  eliminative  metabolism,  has  very  properly  been  long 
considered  one  of  the  chief  causes  of  rheumatism,  and  it  is  probable  that  the  cause  is 
chemical  rather  than  bacterial.  Certainly  an  excess  of  uric  acid  exists  in  the  blood  of  most 
rheumatics. 

Diagnosis. — The  chief  surgical  interest  in  this  disease  will  lie  in  the 
effort  to  differentiate  the  acute  condition  of  joint-inflammation  from  septic 
hygienic  and  other  processes  in  the  joint,  from  epiphysitis,  acute  arthritis, 
osteomyelitis,  and  tubercular  disease.  Hundreds  of  tubercular  joints 
are  lost  through  the  mistaken  diagnosis  of  rheumatism.  In  children  it 
would  be  far  better  to  adopt  the  rule  that  rheumatism  of  a  single  joint 
without  positive  symptoms  never  occurs.  The  slow  onset  of  tubercular 
disease  and  the  early  rigidity  of  muscles  are  sufficiently  distinctive  to 
establish  a  diagnosis. 

In  acute  infectious  processes  in  the  bone  the  rapid  progress  of  the 
symptoms  and  the  speedy  advancement  to  suppuration  are  diagnostic. 
The  habit  of  attributing  all  joint-pains  to  rheumatism  is  one  of  the 
most  fateful  of  errors. 

Treatment. — Medicinally,  the  treatment  consists  in  the  employment 
of  salicylates,  salol,  oil  of  wintergreen,  methylic  salicylate,  etc.  Sper- 
min  has  also  been  advocated  for  its  metabolic  action. 

Surgically,  local  anodynes,  solutions  of  sodium  carbonate,  with  diy 
and  moist  heat,  will  relieve  pain.  The  ordinary  electric  bulb  makes  an 
effective  and  speedy  means  of  applying  dry  heat.  The  application  of 
the  X-rays  to  acute  rheumatic  joints  has  been  stated  to  be  helpful  in  the 
arrest  of  the  process. 

During  the  acute  stage  absolute  rest  in  bed  and  the  application  of 
splints  to  limit  motion  and  thus  prevent  inflammatory  deposits  are 
essential.  Fibrinous  exudates  are  best  absorbed  by  the  use  of  super- 
heated dry  air,  which  assists  in  the  softening  of  the  exudate  and  then 
in  its  being  carried  on  by  the  increased  local  circulation.  The  appa- 
ratus for  the  application  of  superheated  air  consists  of  a  brass  cylinder 
(Fig.  345)  30  inches  long  by  16  inches  in  diameter,  thickly  lined  with 
asbestos  and  magnesia,  and  heated  below  by  gas,  alcohol,  or  oil.     One 

1  Annal.  de  V Institut  Pasteur,  Nov.,  1897  ;  Gaillard's  Med.  Jour.,  March,  1898 

2  Medical  Standard,  April,  1898. 


/O.s 


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end  of  such  cylinder  consists  of  a  canvas  sleeve  with  a  drawing  string 
to  grasp  the  inserted  leg  or  arm.  A  special  sleeve  with  four  flaps  per- 
mits adaptation  to  shoulder,  hip,  back,  or  loins,  thus  rendering  helpful 
service  in  lumbago,  sprained  shoulder,  etc.  The  part  to  be  treated  is 
protected  by  a  number  of  layers  of  cheese-cloth,  gauze,  or  lint,  loosely 
held  in  place.  If  tightly  bandaged,  blistering  is  apt  to  occur.  The 
limb  should  be  inserted  at  about  1500  F.,  and  although  the  boiling 
point  of  water  is  212°  F.,  yet  the  majority  of  patients  will  bear  2500  F. 
after  the  first  treatment  without  burning.  The  highest  point  that  I 
have  reached  without  injury  has  been  3830  F.     The  perspiration  of  the 


FlG.  345. — Cylinder  for  the  application  of  superheated  dry  air. 


part  treated  is  absorbed  by  the  gauze  and  dissipated  in  the  intense  dry 
heat  of  the  cylinder,  or  carried  off  through  sliding  trap-doors,  thus 
avoiding  blistering.  The  treatment  may  be  continued  from  thirty  to 
sixty  minutes,  after  which  the  part  should  be  bathed  with  alcohol,  or 
massaged  with  cocoanut  oil  to  assist  in  absorption.  Gentle  passive 
motion  is  helpful. 

In  many  cases,  while  the  local  temperature  is  elevated,  the  general 
temperature  is  not  raised  more  than  a  fraction  of  a  degree.  The  heart's 
action  is  increased  from  5  to  10  beats,  and  profuse  perspiration  is  the 
rule,  requiring  the  removal  of  surplus  clothing.  Softening  of  the 
deposits  following  acute  rheumatic  arthritis  is  marked,  and  their  absorp- 
tion greatly  promoted.  The  free  use  of  water  and  other  diuretics  is 
necessary  to  carry  off  gouty  and  other  products  that  have  been  forced 
into  the  circulation.  In  chronic  rheumatism  a  varying  degree  of 
permanent  good  is  secured  and  pain  is  relieved.  In  rheumatoid 
arthritis  the  benefit,  of  course,  is  not  so  great,  but  comfort  is  obtained. 
In  the  absorption  of  inflammatory  deposits,  and  in  the  "  rheumatic 
pains"  that  so  commonly  follow  sprains,  fractures,  etc.,  the  greatest 


ARTHRITIS. 


709 


benefit  is  secured.  In  lumbago,  sciatica,  and  shoulder-sprains  decided 
comfort  is  realized. 

In  tubercular  joints  the  process  theoretically  is  so  dangerous  that  the 
writer  has  hesitated  to  make  the  clinical  experiment,  lest  the  tubercular 
infecting  bacilli  be  swept  on  in  the  circulation  to  involve  fresh  areas, 
or  lest  undue  activity  be  developed  in  the  local  diseased  area. 

When  partial  ankylosis  exists,  much  assistance  will  be  rendered  by 
massage  and  passive  movements  following  the  softening  process  secured 
by  the  use  of  hot  air;  or  hot  douches  may  be  practised.  Varying 
forms  of  gymnastics  are  also  helpful. 


FIGS.  346,  347. —  Effect  of  chronic  rheumatoid  arthritis  on  the  hands  (Adams). 

O'Conor1  argues  that  rheumatism  is  an  acute  septic  arthritis  anal- 
ogous to  the  gonorrheal  or  pyemic  variety,  and  that  the  joint-structures 
are  incubators  for  the  subsequent  distribution  of  the  poison  through 
the  blood  vessels  to  the  heart  and  to  the  other  articulations.  Reason- 
ing from  his  experience  of  10  cases,  he  advocates  the  immediate  open- 
ing of  the  joint  and  irrigation  with  I  :  5000  bichlorid  and  drainage. 

Rheumatoid  Arthritis.— Synonyms.— Arthritis  deformans; 
Osteitis  deformans;  Osteo-arthritis ;  Dry  arthritis;  Arthritis  sicca; 
Rheumatic  gout;  Nodosities  of  the  joints. 

Pathology. — Attempts  have  been  make  to  discover  the  specific  organism  producing  this 
disease.  Bannatyne  and  Wohlmann  claim  to  have  successfully  demonstrated  the  presence 
of  a  minute  dumb-bell  bacillus  which  can  be  stained  by  gentian  violet  and  by  anilin-methy- 
lene  blue.  Whether  this  condition  is  due  to  microbes  or  to  inherent  elements  in  the  blood, 
hereditary  or  acquired,  the  result  is  one  of  slow,  steadily  progressive  proliferation  of  cells, 

1  Glasgow  Med.  Jour.,  Oct.,  1897  ;  Phila.  Med.  Jour.,  Feb.,  1S98  ;  Annals  of  Surgery ; 
Feb.,  1898,  April,  1899. 


yio 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


tending  to  destruction  of  joint-cartilage  with  deposition  of  bone-nodosities  within  and  around 
the  articulations.  These  depositions  under  attrition  may  harden  and  become  eburnated,  and 
progressive  fixation  of  the  joint  may  occur. 

Recent  investigations1  in  a  tomb  of  the  Fifth  Dynasty  revealed  a  skeleton  at  least  5500 
years  old  showing  polyarticular  degenerative  changes  of  cartilages  and  bones,  with  nodosi- 
ties, eburnation,  and  grooves  characteristic  of  rheumatoid  arthritis. 

Etiology  and  Symptoms. — While  rheumatism  and  gout  are  fre- 
quently found  in  the  ancestry  of  these  sufferers,  yet  its  existence  prob- 
ably exerts  no  greater  influence  than  antecedent  debilitating  and 
exhaustive  conditions,  such  as  lack  of  sunshine,  gonorrheal  rheu- 
matism, alcoholism,  etc. 

The  monarticular  form  of  this  disease  is  usually  found  in  elderly 
people,  and,  as  seen  by  the  surgeon,  exists  chiefly  as  one  form  of  senile 


•■■-. 


» 


Fig.  348. —  Shoulder-joint  in  a  case  of  chronic  rheumatoid  arthritis  (Adams). 


arthritis  of  hip  and  knee.  The  polyarticular  variety  is  found  in  adults ; 
occasionally  in  children.  The  onset  is  slow,  with  exacerbations  of 
pain,  limping,  progressive  interference  with  joint-motion,  creaking  and 
grating  within  the  joint,  and  ultimately  ankylosis.  Sometimes  it  involves 
almost  every  joint  of  the  body,  including  the  spine. 

A  distinction  should  be  made  between  osteo-arthritis  and  rheuma- 
toid arthritis,  the  latter  being  distinguished  by  swelling  of  the  joint 
during  the  acute  and  subacute  stages,  followed  by  atrophy  in  the 
region  of  the  joint,  and  by  atrophy  of  the  muscles  with  hyperexten- 
sion.     In  osteo-arthritis  there  is  great  proliferation  of  cartilage  with 

1  Brit.  Med.  Jour.,  Dec.  4,  1897;    Univ.  Med.  Mag.,  Feb.,  1898. 


ARTHRITIS. 


yll 


deposit  of  osteophytes  (Heberden's  nodes) ;  distortion  is  greater,  and 
the  joint  remains  permanently  larger.  In  the  ringers  the  deformity  is 
usually  hyperextension  with  lateral  distortion  and  atrophy  of  the 
muscles  (Figs.  346,  347).  In  the  larger  joints  flexion  is  the  rule. 
The  character  of  the  deposit  about  the  shoulder  and  hip  is  well  illus- 
trated by  the  accompanying  illustrations  (Figs.  348-350). 

Diagnosis. — Diagnosis  from  tubercular  disease  will  depend  upon 
the  history  of  the  case  and  the  density  of  the  nodosities,  in  contradis- 
tinction to  doughy  thickening.  In  tuberculosis,  also,  muscular  rigidity 
will  occur  early  and  be  more  marked.  The  onset  in  both  cases  is 
slow.  In  tuberculosis  the  condition  tends  to  suppuration  ;  in  osteo- 
arthritis, to  stalactitic  deposits  around  the  joints.  Depositions  in  the 
muscles  will  lead  to  a  diagnosis  in  myositis  ossificans. 

Prognosis. — The  disease  is  most  insidious  and  persistent,  often 
running  a  course  of  from  ten  to  twenty  years. 

Treatment. — Granting  that  the  disease  is  of  bacterial  origin,  the 
best  medical  eliminatives  would  be  guaiacol  carbonate,  creosotal,  and 
benzosol  (the  first-named  drug  being  less  objectionable  to  the  stomach), 
in  doses  varying  from  5  to  1 5  grains,  and  increased  as  advisable.     This 


Fig.  349. — Acetabulum  of  an  adult  who 
had  long  suffered  from  chronic  rheumatoid 
arthritis  (Adams). 


Fig.  350. —  Posterior  view  of  head,  neck, 
and  superior  extremity  in  a  case  of  chronic 
rheumatoid  arthritis  of  the  hip  (Adams). 


drug  is  supposed  to  combine  with  the  bacterial  toxins,  and  by  elimi- 
nation of  the  guaiacol  sulphate  to  have  a  beneficial  action.  Other 
helpful  medication  consists  in  the  use  of  arsenic,  Lugol's  solution  of 
iodin,  cod-liver  oil,  potassium  iodid.  and  digestives.  Locally,  massage 
with  guaiacol  and  olive  oil  gives  comfort,  and  hot  baths  are  recom- 
mended, especially  if  thermal  springs  are  available.     The  application 


712  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

of  superheated  dry  air  as  described  on  page  707  is  helpful  in  relieving 
pain  and  in  absorbing  deposit,  the  temperature  being  carried  to  from 
2500  F.  to  4000  F.  according  to  the  comfort  of  the  patient. 

Surgical  treatment  should  vary  according  to  the  type  of  the  disease 
— that  is,  in  ostco-arthritis  motion  should  be  slight  and  guarded  ;  in 
rheumatoid  arthritis  rest  should  be  enforced  during  the  acute  stage, 
but  more  vigorous  exertion  is  advisable  after  the  inflammatory  process 
has  subsided.  Active  and  passive  motions,  even  under  anesthesia,  are 
helpful,  and  the  use  of  the  articulation  is  to  be  encouraged.  Some- 
times, but  rarely,  electricity  and  electric  radiant  baths  are  of  service. 

Surgically,  benefit  is  derived  in  some  cases  from  tenotomy  of  the 
contracted  tendons,  especially  the  hamstrings,  with  forcible  straighten- 
ing. This  prevents  atrophy  and  improves  locomotion.  If  a  single 
joint  is  deformed,  chiselling  of  the  nodosities  might  prove  of  temporary 
service  in  permitting  locomotion. 

The  JSf-rays  are  helpful  in  diagnosing  this  disease  from  other  joint- 
conditions. 

Gonorrheal  Arthritis. — Synonyms. — Gonorrheal  rheumatism  ; 
Gonorrheal  arthritis  ;  Tripper  rheumatismus  ;  Gonocele  ;  Urethral  rheu- 
matism ;  Urethral  synovitis  ;  Arthropathie  blennorrhagique  ;  Rheuma- 
tismus gonorrhoisch  ;    Rheumatismus  blennorrhoicus. 

Etiology. — This  disease  is  the  result  of  septic  infection  due  to  the 
implantation  of  gonococci,  or  their  ptomains,  or  of  secondary  infections 
in  the  fertile  soil  of  the  articulations.  The  amount  of  urethral  inflam- 
mation bears  no  relation  to  the  attack.  The  presence  of  gonococci  is 
usually  demonstrable  in  the  fluid  from  an  infected  joint  both  by  the 
microscope  and  by  cultures.  When  non-discoverable,  the  examination 
may  have  been  made  too  late,  or  the  free  exudate,  and  not  the  tissues, 
may  have  been  selected.  Even  after  the  disappearance  of  the  gono- 
cocci the  resultant  pathological  changes  may  continue. 

Symptoms. — The  onset  is  usually  sudden,  in  the  third  or  fourth 
week  of  an  attack  of  gonorrhea,  and  is  sometimes,  but  not  always, 
accompanied  by  a  disappearance  of  the  local  discharge.  It  may  attack 
any  joint  in  the  body,  but  preferably  the  knee,  ankle,  and  wrist.  The 
progress  of  the  disease  is  essentially  that  of  a  septic  arthritis.  Often 
there  is  rapid  destruction  of  the  joint-structures,  with  suppuration,  or 
there  may  be  ankylosis  without  suppuration,  especially  at  the  wrist  and 
carpus.  Swelling  is  marked ;  pain  and  constitutional  symptoms  are 
severe  at  night.  Gonorrheal  bursitis  may  occur  beneath  the  insertion 
of  the  tendo  Achillis  (achillodynia)  or  above  the  patella. 

Diagnosis. — The  recent  existence  of  urethral  disease  will,  unless 
concealed,  lead  the  surgeon  in  the  proper  direction. 

Treatment. — Treatment  should  be  promptly  instituted,  especially 
if  there  has  been  a  subsidence  of  the  urethral  discharge,  and  if  acute 
symptoms  are  present.  Absolute  rest  of  the  joint  or  joints  is  essen- 
tial, and  hot  irrigations  of  the  urethra  with  sterile  water  or  a  weak 
solution  of  potassium  permanganate  may  be  practised.  There  should 
be  absolute  fixation  of  the  joint  with  gypsum  or  other  splint  until 
acute  inflammatory  symptoms  have  passed,  after  which  the  joint  should 
be  gently  moved  to  prevent  the  ever-present  tendency  to  ankylosis. 
As  soon  as  evidences  of  suppuration  appear,  incision  and  thorough 


ARTHRITIS.  713 

cleansing  with  bichlorid  (1  :  5000)  or  formaldehyd  (1  :  2000)  and  com- 
plete drainage  of  the  joint  are  requisite.  Subsequent  ankylosis  should 
be  treated  by  forcible  straightening,  tenotomies,  etc. 

Tubercular  Osteitic  Arthritis. — Synonyms. — Joint-tuberculo- 
sis ;  White  swelling ;  Gelatinous  or  Pulpy  or  Fungous  degeneration  ; 
Strumous  arthritis. 

Pathology. — Tuberculosis  in  the  region  of  the  joints,  whether  of 
the  trunk  or  extremities,  is  essentially  a  bone-tuberculosis  (osteitis), 
although  it  occasionally  originates  in  the  synovial  membrane  (arthritis). 
It  is  a  disease  of  infection,  caused  by  the  presence  of  the  tubercle 
bacillus,  and  accompanied  by  the  formation  of  circumscribed  tubercular 
nodules,  in  the  tissues  adjacent  to  and  within  the  diseased  joints. 

A  tubercular  nodule  in  bone  consists  of  a  collection  of  round  and  variously  formed  cells, 
the  most  constant  of  which  is  the  epithelioid.  These  cells  (platycytes)  resemble  endothe- 
lium, and  are  of  finely  granulated  protoplasm  with  small  ovoid  nuclei.  In  addition  to  these 
epithelioid  bodies,  peripherally  polynucleated  giant-cells  (macrophagocytes)  are  very  con- 
stantly found,  grouped  in  masses  and  fewer  in  number.  Tubercle  bacilli,  rod-shaped,  may 
be  found  within  or  adherent  to  any  of  these  cells.  The  epithelioid  cells  are  probably 
derived  from  the  blood-vessels  or  by  proliferation  of  the  previously  existing  cells,  as  a  result 
of  the  activity  induced  by  the  presence  of  the  bacilli. 

The  active  central  cells  are  probably  derived  from  leukocytes  ;  the  giant-cells  may  be 
fused  epithelial  cells,  or  their  origin  may  be  from  degenerated  cells  by  proliferation  without 
separation  of  protoplasm,  even  although  the  nuclei  divide.  Small  round  cells  similar  to 
those  found  in  young  granulation-tissue  also  occupy  a  considerable  space  in  the  tuberculous 
nodule,  and  blood-plaques  are  sometimes  seen. 

When  a  tuberculous  nodule  retrogrades,  polynuclear  leukocytes  make  their  appearance  ; 
fattv  degeneration  takes  place,  and  caseation  with  liquefaction  follows.  If  favorable  fibroid 
encapsulation  takes  place  from  an  erected  wall  of  defence,  calcification  will  occur,  and  the 
debris  of  bacilli  and  their  ptomains  may  remain  quiescent  for  a  long  period  of  time,  or  the 
entire  mass  may  work  its  way  toward  the  surface  and  be  discharged  in  the  form  of  a  cold 
abscess.  The  irritation  caused  by  the  tubercle  bacilli  often  excites  inflammatory  processes, 
and  if  staphylococcus  infection  is  added,  suppuration  ensues,  and  the  tubercular  nodule  may 
finally  be  eliminated  by  this  method  ;  but  suppuration  is  not  an  essential  part  of  a  tubercular 
process.  The  changes  in  a  tubercular  nodule  closely  resemble  those  seen  in  ordinary  inflam- 
mation. 

The  action  of  bacilli  is  essentially  destructive,  but  their  presence  immediately  arouses  a 
procedure  which  has  been  already  described  as  "the  method  by  which  organisms  attempt  to 
render  inert  noxious  elements  introduced  from  without  or  arising  from  within."  Following 
hyperemia,  congestion,  stasis,  and  emigration  of  red  and  white  cells,  phagocytosis  becomes 
active,  and  a  process  beneficial  to  the  tissues  is  aroused,  since  rapid  tissue-changes  are  inimical 
to  the  growth  and  development  of  bacilli. 

Bacillary  infection  may  occur  from  without,  leaving  no  trace  of 
local  infection  at  the  atrium,  or  from  within  through  the  blood-vessels. 
Lodgement  of  these  micro-organisms  having  occurred  in  or  near  a 
joint  in  a  healthy  individual,  the  invaders  are  overpowered  by  the 
defenders,  and  no  injury  results.  Under  the  influence  of  slight  injury, 
however,  or  from  inherent  cell-weakness,  this  defensive  power  having 
been  temporarily  or  permanently  lost,  a  foothold  is  gained  and  the 
point  of  attack  fortified.  A  tubercular  nodule  is  the  result.  Garrisoned 
on  this  vantage  ground,  the  bacilli  or  their  spores  lurk  prepared  to 
renew  the  assault  at  any  near  or  remote  moment  when  the  defenders 
are  off  duty  or  are  engaged  in  repelling  other  invaders,  or  when  their 
resistive  powers  are  lessened  by  traumatism,  by  fever,  or  by  other 
cause. 

The  important  part  that  heredity  plays  in  this  process  is  simply  that  the  cells  are  less 
resistive  and  less  capable  of  withstanding  assault ;  such  impaired  vitalization  having  been 
imparted   through   spermatozoid  or  ovum  in  the  same  manner  as  are  other  characteristics. 


7H 


INTERXATJONAL    TEXT-BOOK  OE  SURGERY. 


The  term  heredity  implies  a  condition  of  tissue,  not  a  disease.  Thus  it  is  evident  that  the 
infection  of  tuberculosis  is  influenced  by  ancestral  legacies,  by  personal  habits  of  life,  and 
by  temporary  and  permanent  local  conditions.  When  the  distinctive  symptoms  of  joint- 
tuberculosis  are  present,  the  non-existence  of  tubercle  in  the  family  history  is  of  little 
moment,   save  for  prognosis,   since  any  individual   may  develop   local    tuberculosis. 

The  abolition  of  the  old  terms  "white  swelling,"  scrofulous  joint,  etc.,  which  served 
their  purpose  for  clinical  description,  has  been  due  to  realization  of  the  unity  of  the  tubercu- 
lous process.  The  use  of  the  term  scrofulous  still  serves  clinically,  however,  to  denote  a 
non-resistant  condition  of  the  tissues,  subjecting  the  individual  to  a  degenerative  process 
which  tends,  not  to  organization,  but  to  disintegration  of  the  structures.  Traumatism, 
heredity,  scrofulosis,  environment,  and  local  conditions  are  all  concerned  in  the  production 
of  local  bone-tuberculosis.  Traumatism  certainly  plays  a  most  important  part  in  this  patho- 
logical process  by  setting  up  an  inflammatory  condition  which  destroys  the  power  of  resist- 
ance of  the  tissue-cells  against  the  enemy — the  tubercle  bacillus.  In  severe  injuries  cell- 
resistance  is  more  thoroughly  aroused  than  in  slight  joint-contusions,  and  infection  by  the 
bacillus  is  thereby  more  readily  repelled. 

Tuberculosis  of  the  synovial  membrane,  if  primary,  may  cause  a  diffused  thickening  of 
the  membrane  or  the  direct  formation  of  tubercular  nodules.  Pulpy  degeneration  follows, 
and  as  the  supply  of  blood  diminishes,  the  cartilage  loses  its  vitality,  macerates,  and  becomes 
infiltrated  with  tubercular  granulations.  Gelatinous  infiltration  occurs,  from  perforation  of 
the  synovial  membrane  and  infection  of  the  surrounding  tissues  by  the  escape  of  tubercle 
cells. 

Tubercular  deposits  in  the  extremities  of  bones  usually  occur  primarily  in  or  near  an  epi 
physeal  line.  When  the  tubercular  process  advances  to  the  articular  surface,  the  cartilage 
may  be  loosened  almost  en  masse,  or  it  may  be  eroded,  while  the  underlying  layer  of  bone- 
tissue  becomes  carious. 

The  deposit  of  tubercle  not  infrequently  causes  a  rarefying  osteitis  in  the  immediate 
neighborhood  of  a  joint,  although  the  presence  of  bacilli   may  not  be  demonstrable.      The 

Haversian  canals  are  enlarged  coinci- 
dently  with  absorption  of  the  trabecular 
and  the  development  of  granulation-tis- 
sue. Caries  of  the  bone  of  the  fungous 
variety  may  follow,  with  an  excessive 
production  of  granulation-tissue.  A 
considerable  portion  of  the  bone  and 
joint  may  be  destroyed — caries  necrotica  ; 
or  a  wedge-shaped  portion  of  the  bone 
may  become  necrosed  from  a  tubercular 
infarct.  Even  when  an  infarct  does  not 
exist,  the  deposit  of  tubercular  material 
so  retards  circulation  that  articular  bone- 
death  may  result  from  loss  of  nutrition. 
In  some  cases  a  sequestrum  results,  but 
more  frequently  the  bone  becomes  slowly 
carious,  or  an  abscess  forms.  The  pre- 
cise form  of  resultant  death  will  depend 
upon  the  rapidity  or  violence  of  the 
process,  or  upon  the  existence  of  microbic 
osteomyelitis;  but  the  latter  condition  is 
more  common  in  the  shaft  of  the  bone  than  at  the  extremities. 

Although  the  initiatory  process  is  usually  in  the  bone,  yet  the  violence  of  the  onset  may 
sometimes  appear  primarily  in  the  joint-structures,  as  noted  in  the  accompanying  microscopi- 
cal sections  taken  from  the  insertion  of  the  round  ligament  into  the  acetabulum  (Figs.  351, 
352).  In  this  case,  which  was  under  my  care,  and  in  which  the  patient  died  of  acute  tuber- 
cular meningitis,  the  epiphysis  contained  no  caseating  nodules,  but  characteristic  foci  were 
found  in  the  round  ligament.  The  changes  demonstrated  were  those  chiefly  of  increased 
cell-activity,  and  not  of  distinct  tuberculosis. 

Symptoms  and  Etiology. — Tubercular  joint-disease  may  occur  at 
any  age,  even  as  early  as  two  months.  Lack  of  food  and  sunshine,  bad 
air,  and  intemperance  of  parents  are  the  most  common  factors.  In  chil- 
dren a  large  proportion  of  diseases  of  the  joints  are  tubercular  in 
character,  while  in  adults  the  non-tubercular  conditions  preponderate. 

In  cases  of  decided  injury  the  hyperemia,  swelling,  and  pain  in  the 
region  of  the  joint  may  be  acute;  but  these  are  rather  true  of  synovitic 


Fig.  351. 


-Attachment  of  the  ligamentum  teres  to 
the  head  of  the  femur ;   X  So. 


ARTHRITIS. 


715 


cases  than  of  tubercular  osteitic  arthritis.  Often  the  pain  is  not  located 
at  the  joint,  but  is  manifested  at  some  distant  point.  Reflex  pains  may- 
be present  in  the  knee,  hip,  abdomen,  arm,  or  chest.  The  contour  is 
altered,  and  the  carriage  of  the  body  in  standing,  stooping,  walking, 
etc.  is  changed. 

In  non-acute  cases  the  period  between  the  reception  of  the  injury 
and  the  development  of  symptoms  may  be  delayed  for  many  months. 
First,  a  slight  uneasiness  or  restlessness  of  the  limb  may  manifest  itself 
at  night — a  discomfort  rather  than  a  pain.     In  hip-infection  this  distress 

■•"-'l||&»*! 

■''-'. 


^ ■     ~^    V-^^-". v£5.^fc^ ?«^W 


FlG.  352. — Attachment  of  the  synovial  membrane  to  the  periphery  of  the  articular  cartilage  of 
the  head  of  the  femur ;   X  30. 


may  be  referred  first  to  the  region  of  the  adductors,  then  down  near  the 
inner  condyle.  At  first  the  child  limps  only  at  times,  afterward  more 
persistently. 

If  the  spine  is  the  seat  of  infection,  movement  of  the  vertebrae  will 
be  avoided  by  carrying  the  body  rigidly  and  by  cautious  stooping,  while 
colicky  pains  will  disturb  the  patient  at  night.  The  first  stage  is  a  vari- 
able one,  with  retardation  or  with  rapid  advancement  under  slight 
injuries.  Such  a  patient  stripped  and  examined  will  show,  first  of  all, 
rigidity  of  the  part  involved — muscular  protection.  This  rigidity  is  per- 
sistent from  the  earliest  onset,  and  is  the  most  characteristic  symptom. 
Tenderness,  swelling,  and  deformity  are  variable :  the  diagnosis  should 
be  made  before  these  appear,  if  treatment  is  to  be  of  decided  avail. 

Richardson  has  advocated  the  systematic  auscultation  of  joints  with  single  or  double 
stethoscope.  In  healthy  articulations  no  sound  will  be  elicited,  but  in  disease  one  may 
obtain  simply  dry  frictions,  dry  grating,  moist  crepitant,  and  coarse  crepitant  sounds. 

In  the  second  stage,  that  of  joint-effusion,  marked  limping  comes  on 
as  the  patient  endeavors  to  shorten  the  time  of  impact  of  the  sore  joint- 
surfaces.  Soon  "  starting  pains  "  or  "  night-cries,"  caused  by  the  alter- 
nate relaxation  and  contraction  of  the  guarding  muscles  as  they  bring 
into  contact  the  two  inflamed  joint-surfaces,  will  seriously  disturb  the 
sleep  of  the  patient.  Deformity,  usually  in  the  direction  of  flexion, 
becomes  more  marked  as  the  muscles  increase  their  efforts  at  protec- 


/IO  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

tion,  and  reflex  pains  in  chest,  abdomen,  or  limbs  are  indicated,  often  at 
a  considerable  distance  from  the  part  involved.  In  caries  of  the  spine 
local  tenderness  is  the  exception  ;  at  the  other  joints  it  is  usually,  but 
not  invariably,  present.  Alteration  of  contour  speedily  follows,  the 
swelling  being  palpable  in  the  region  of  the  joint,  and  doughy  indura- 
tion rapidly  increases.  Atrophy  of  the  muscles  also  alters  the  normal 
outlines  of  the  various  regions  involved.  The  whole  aspect  is  so  char- 
acteristic that  a  diagnosis  of  "  rheumatism  "  can  be  explained  only  by 
ignorance  or  by  carelessness  in  examination. 

The  later  or  third  stage  is  one  of  rupture  of  the  joint-capsule,  with 
infection  and  destruction  of  tissues,  usually  suppurative.  Spine,  ankle, 
and  knee  distortions  will  not  greatly  alter  their  position  at  this  stage ; 
but  at  the  hip,  abduction  is  changed  to  adduction,  and  lengthening  to 
shortening,  both  apparent  and  real,  as  bone-destruction  progresses. 
Great  thickening  in  the  region  of  the  joint  is  present,  with  subsequent 
softening  and  formation  of  abscesses  or  ankylosis. 

Diagnosis. — Simple  synovitis  and  acute  rheumatic  arthritis  are 
sudden  in  their  onset,  with  speedy  rise  in  pulse  and  temperature ;  the 
latter  disease  may  attack  several  joints.  The  history  in  both  cases  will 
be  quite  different  from  the  sequence  of  symptoms  seen  in  tubercular 
arthritic  osteitis — slow  onset,  rigidity  of  the  surrounding  muscles, 
flexion  of  the  joint,  and  atrophy. 

In  children,  when  a  single  joint  is  affected,  the  inference  should  be 
always  in  favor  of  tubercular  disease.  Mono-articular  rheumatism  in  chil- 
dren without  other  positive  symptoms  should  be  absolutely  discarded 
from  the  surgeon's  mind.  Hundreds  of  children  are  yearly  permitted  by 
the  fateful  myth  of  "  rheumatism  "  to  pass  beyond  the  point  where 
abortive  treatment  is  possible  ;  loss  of  joint-function,  loss  of  limb,  and 
even  of  life,  are  the  result  of  such  errors. 

The  onset  of  infantile  paralysis  is  sometimes  puzzling,  as  the  child 
may  cry  when  handled.  The  gait  when  the  patient  is  examined  naked 
will  show  a  limp  that  is  not  one  of  inflammation,  but  one  of  debility. 
There  will  be  increased  motion  and  laxity  of  the  joint,  not  rigidity,  and 
no  thickening. 

Inherited  syphilis,  it  should  be  remembered,  may  announce  itself  in 
joint-osteitis,  especially  in  the  spine ;  but  the  tuberculous  reflex  spasm, 
rigidity  of  muscles,  night-cries,  and  atrophy  of  muscles  are  certainly 
distinctive  enough,  when  present,  to  make  diagnosis  assured.  Peri- 
arthritis, bursitis,  and  the  beginning  of  osteosarcoma  are  at  times  dif- 
ficult of  differentiation. 

Treatment  of  Joint=TubercuIosis. — As  prevention  is  always  better 
than  cure,  so  is  hygienic  care  better  than  medicine  in  the  retardation 
and  cure  of  joint-tuberculosis.  The  removal  of  children  suffering  with 
joint-infection  from  an  atmosphere  loaded  with  germs  or  with  the  dried 
sputum  of  a  phthisical  patient  is  essential.  Next  comes  sunlight,  which, 
aside  from  its  beneficial  effect  upon  a  patient,  has  an  especially  destruc- 
tive influence  upon  tubercular  bacilli.  Colorado's  advantages  lie 
largely  in  the  increased  hours  of  sunshine.  Fresh  air  is  an  absolute 
necessity,  and  cheerful  surroundings  and  good  food  come  next.  With 
these  aids  one  has  but  little  need  for  the  materia  medica.  Digestives, 
tonics,  and  nutritives  have  their  place  where  more  essential  conditions 


ARTHRITIS.  7l7 

are  lacking.  A  tubercular-joint  patient  should  actually  live  in  the 
open  air,  and  by  the  employment  of  the  bed-frame  this  can  be  accom- 
plished even  where  strict  confinement  to  bed  is  required.  The  sea  air, 
especially  where  it  is  dry,  as  on  the  New  Jersey  coast,  has  a  most 
beneficial  effect  upon  children  with  joint-trouble,  although  it  frequently 
has  the  contrary  influence  upon  phthisis  pulmonalis.  An  out-door  life 
in  the  country  is  beneficial,  and  even  in  a  crowded  city  its  results, 
though  not  so  obvious,  are  still  markedly  helpful. 

The  beneficial  effect  of  absolute  fixation  of  tubercular  joints  is 
thoroughly  proved.  It  is  the  superadded  inflammatory  condition,  and 
not  tubercular  disease,  that  is  likely  to  produce  ankylosis.  Rest  is  the 
only  measure  that  can  abort  a  threatened  infection.  Traction  assists 
in  securing  rest  by  resisting  muscular  contraction,  modifying  joint- 
pressure,  and  relieving  pain  and  deformity. 

Counterirritation,  so  much  relied  upon,  is  practically  useless,  save 
as  combined  with  rest.  The  benefit  obtained  by  the  use  of  the  actual 
cautery  in  former  days  was  doubtless  largely  due  to  the  fact  that  it  put 
the  patient  in  bed  for  many  weeks  and  prevented  the  use  of  the 
inflamed  joint. 

During  the  acute  painful  stage,  extension  by  weight  and  pulley  can 
be  maintained  in  the  horizontal  position  while  the  patient  enjoys  all 
the  advantages  of  out-door  life  by  the  use  of  a  simple  tray  or  bed- 
frame  or  stretcher,  consisting  of  a  framework  of  gas-pipe  or  wood 
covered  with  canvas  in  one,  two,  or  three  sections.  This  can  be  laid 
upon  a  bed  at  night,  while  during  the  day  the  patient  can  be  carried 
upon  it  in  the  horizontal  position  and  enjoy  the  advantages  of  fresh  air. 
Such  frame  can  be  carried  in  arms  without  the  patient  being  disturbed 
from  the  dorsal  decubitus ;  or  it  can  be  placed  upon  the  platform  of  a 
long  baby-coach,  or  rested  upon  chairs  or  trestles  upon  a  porch  or 
under  shade  trees,  and  at  night  placed  upon  a  bed. 

Requisite  extension  can  be  temporarily  secured  by  elastic  traction 
to  an  upright  at  the  foot  of  the  frame,  or  at  the  head  in  spinal  disease. 
A  good  rule  in  hip-disease  is  to  keep  the  patient  in  the  horizontal  posi- 
tion for  three  months  after  the  cessation  of  all  pain.  Extension  may 
also  be  made  by  one  of  the  forms  of  traction-apparatus. 

Fixation  will  be  secured  by  the  employment  of  splints  of  wood,  felt, 
paper,  tin,  leather,  plaster  of  Paris,  or  silicate.  The  joint  should  be 
kept  at  absolute  rest.  The  diagnosis  having  been  firmly  established  in 
the  beginning,  no  motion  should  be  permitted  for  months.  When  the 
acute  stage  has  passed,  the  patient  may  be  fitted  with  a  proper  fixation 
or  traction  splint,  and  treated  on  the  ambulatory  plan  with  crutches, 
high  shoe,  etc.,  as  required.  Gypsum  bandages  form  the  most  com- 
mon dressings. 

Trephining  of  Bone. — Incision  into  or  trephining  of  bone  is  often 
of  service,  if  the  precise  focus  can  be  reached.  It  is  of  special  advan- 
tage where  the  disease  has  commenced  in  the  condyle  of  the  femur,  or 
in  the  great  trochanter,  or  in  the  humeral  or  tibial  epiphyses. 

Ignipuncture. — The  perforation  of  a  tubercular  bone-focus  with  the 
Paquelin  cautery  often  has  a  most  beneficial  effect. 

Injections  of  Antibacillary  Substances. — Injections  of  iodoform, 
chlorid  of  zinc,  alcohol,  or  formaldehyd  into  a  joint  or  into  the  tissues 


718  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

surrounding  a  tubercular  focus  have  been  practised,  and  sometimes 
lauded.  The  writer's  experience  with  this  treatment,  however,  has  been 
unfortunate,  as  even  under  the  most  absolute  cleanliness,  suppuration  in 
many  cases  has  been  rather  hastened  than  retarded.  Boiled  olive  oil 
or  glycerin  with  10  per  cent,  sterilized  iodoform  added  may  be  injected 
hypodermically  either  into  the  joint  or  into  the  surrounding  tissues. 
In  the  latter  case  io  or  15  minims  of  the  mixture  should  be  employed 
at  each  point  of  injection,  and  at  least  one  dram  should  be  used 
altogether;  in  a  joint  an  ounce  of  the  mixture  may  be  employed. 
Pain  from  such  injections  may  be  mitigated  by  the  local  use  of  a  spray 
of  ethyl  chlorid  or  by  Schleich's  tissue-pressure  anesthesia.  The 
sclerogenic  treatment,  or  the  circumferential  injection  at  numerous 
points  of  a  10  per  cent,  solution  of  chlorid  of  zinc,  has  a  decided 
restrictive  effect.  Wood-alcohol  or  formaldehyd  is  also  useful  by  its 
constricting  effect  upon  the  capillaries. 

Injections  of  Antituberculin  Scrum. — The  injection  of  antiphthisin  (a 
sozalbumin  containing  the  germicidal  elements  of  tuberculin),  tuber- 
culin R.,  repeated  injections  of  serum  and  serum-products,  compounds 
of  pilocarpin,  creosote,  etc.,  have  not  been  sufficiently  tested  to  give 
definite  results,  but  they  are  helpful. 

Chronic  Congestive  Method. — The  artificial  chronic  congestive  method 
advanced  by  Bier  for  the  destruction  of  the  tubercle  bacilli  has  not 
been  received  with  much  favor.  The  method  consists  in  surcharging 
the  joint-structures  with  blood  by  a  constricting  elastic  bandage,  the 
congestion  being  carried  to  a  point  of  even  blistering,  etc.,  and  followed 
by  active  and  passive  movements  of  the  articulation  both  during  the 
time  of  constriction  and  afterward.1 

Aspiration. — Aspiration  of  a  joint  or  of  a  cold  abscess  that  con- 
tains the  liquefaction  of  caseation  will  often  result  in  the  absorption  and 
caseation  of  the  tuberculous  mass  and  in  ultimate  cure  without  sup- 
puration. The  process  may  be  repeated  until  positive  evidence  of  pus 
is  found.  Sterile  iodoform  oil  (20  to  50  c.c.)  or  tincture  of  iodin  may 
be  injected  through  the  cannula  of  the  aspirator.  If  the  contents  of  such 
an  abscess  are  found  to  be  sterile,  there  need  be  no  haste  in  opening  it. 

Arthrotomy  (Incision,  Irrigation,  and  Drainage). — The  laying  open 
and  washing  of  a  joint  with  boiled  sterilized  water  or  sterilized  bichlo- 
rid  (1  :  10,000)  or  formaldehyd  (1  :  2000)  is  often  of  great  service  when 
suppuration  has  commenced,  and  is  demanded  when  infection  is  pres- 
ent. Drainage  by  rubber  tubes  or  gauze  packing  is  often  required,  the 
joint  being  filled  with  iodoform  oil.  It  is  almost  unnecessary  to  say 
that  all  operations  should  be  conducted  with  the  utmost  attention  to 
cleanliness. 

Excision  of  Sac. — All  surgeons  now  realize  that  the  sac  of  a  tuber- 
culous abscess  is  not  a  pyogenic  but  a  pyophylactic  membrane — a  wall 
of  defence  and  of  limitation.  When  it  can  be  completely  excised  with 
knife  or  scissors,  such  plan  is  most  desirable  ;  but  in  many  cases  of 
spinal  and  hip  caries  complete  extirpation  is  impossible.  Under  such 
circumstances,  after  excision  of  all  attainable  sections  the  remaining  sac 
should  be  approximately  removed  with  a  hollow  flushing  curet,  infec- 

1  Med.  Press  and  Circular,  May  20,  1894;  Centralb.  fur  Chirurg.,  Leipsic,  1892,  No. 
82;   Berliner  Klinik.,  Nov.,  1895  ;  Brit.  Med.  Jour.,  Dec.  21,  1895. 


ARTHRITIS. 


719 


tion  from  the  disturbed  remaining  areas  being  prevented  by  mopping 
with  tincture  of  iodin,  saturated  solution  of  chlorid  of  zinc,  or  pure 
carbolic  acid.  When  the  sac  cannot  be  thoroughly  dealt  with,  the 
safer  plan  after  incision  and  irrigation  is  to  avoid  all  disturbance  of  the 
membrane  even  by  pressure,  lest  fissure  of  the  wall  permit  a  route  for 
entrance,  and  infection  and  meningitis  result.  In  such  cases  the  cavity 
should  be  injected  with  tincture  of  iodin,  then  filled  with  sterile  iodo- 
form oil  (10  per  cent.),  and  the  wound  closed.  When  pyogenic  cocci 
are  present,  drainage  will  be  required. 

Evasion. — Erasion,  improperly  called  arthrectomy,  is  an   operation 
frequently  employed  in  the  later  or  suppurative  stage  of  joint-disease. 


FlG.  353- — Skiagraph  of  carious  knee-joint  with  erosion  ;  adult. 

It  includes  the  scraping  away  by  gouge,  knife,  or  scissors  of  all  dis- 
eased hard  and  soft  tissues,  leaving  behind  every  possible  healthy  por- 
tion. Thorough  exposure  of  the  articulation  is  necessary,  and  the  ope- 
ration is  most  helpful  in  those  cases  of  arthritis  where  complete  re- 
moval of  the  diseased  area  can  be  accomplished.  In  the  hip,  while  often 
serviceable,  it  is  not  certain  in  its  effects.  In  the  spine  total  removal  is 
impossible,  and  one  must  content  himself  with  thorough  drainage. 
Ankylosis  after  this  operation  is  common,  but  not  universal.  Erasion 
is  most  useful  at  the  wrist,  ankle,  elbow,  and  knee.  In  the  tarsus  and 
carpus  in  children  the  entire  series  of  bones  may  be  taken  away,  and 
yet  a  useful  hand  and  foot  may  be  secured,  sometimes  much  better  than 


•J2Q  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

an  artificial  member.  An  important  consideration  in  the  treatment  of 
children  is  the  saving  of  the  epiphyseal  lines,  thus  ensuring  growth  of 
the  limb,  even  though  repeated  operations  are  necessary. 

Chronic  sinuses  leading  to  dead  bone  should  be  treated  by  erasion 
of  the  diseased  osseous  structures,  excision  of  sinus  walls,  and  cauteri- 
zation with  chlorid  of  zinc  or  tincture  of  iodin. 

Excision. — The  formal  or  typical  excision  of  the  articular  surfaces 
of  diseased  bone  often  destroys  the  epiphyseal  lines  and  checks  future 
growth.  When  the  tubercular  destruction,  however,  is  large  in  extent, 
this  operation  becomes  a  necessity,  even  in  children,  and  is  a  most  val- 
uable agent  in  saving  life  and  limb.  It  is  also  indicated  in  positive 
joint-destruction  in  adults  when  constitutional  symptoms  are  not  so 
severe  as  to  demand  amputation.  The  determination  as  to  erasion  or 
excision,  or  of  interference  with  ankylosed  tubercular  joints  where  the 
process  has  subsided,  may  often  be  effectually  decided  by  the  employ- 
ment of  the  X-rays,  as  the  extent  of  the  destructive  process  can  be 
very  accurately  delineated  (Fig.  353). 

Amputation. — Sacrifice  of  a  limb  is  a  procedure  that  is  not  infre- 
quently demanded  in  advanced  joint-disease  in  adults,  but  should  be 
avoided  in  children,  except  in  pronounced  and  absolute  destruction. 
Erasion,  even  if  several  times  repeated,  and  excision,  with  constitutional 
treatment,  are  preferable  in  the  young. 

Neuropathic  Arthritis,  Spinal  Arthropathy,  or  Charcot's 
Disease  of  the  Joints. — In  1831,  long  before  Charcot's  observations, 
J.  K.  Mitchell,  of  Philadelphia,  advanced  the  idea  of  an  arthropathy 
associated  with  a  neuropathy. 

Spinal  arthropathy  is  the  name  given  to  peculiar  degenerations  of 
the  joint-structures  occurring  in  the  course  of  spinal-cord  lesions, 
especially  locomotor  ataxia,  tabes,  syringomyelia,  etc. 

Etiology. — The  essential  cause  is  a  degeneration  of  the  spinal  cord, 
steadily  advancing  in  the  central  axis,  with  secondary  nutritive  changes 
in  the  articulations,  which,  under  certain  circumstances,  lead  to  destruc- 
tion first  of  the  synovial  membrane  and  fringes,  then  of  the  cartilage, 
and  finally  of  the  bone.  These  changes  are  slow  in  character,  and  are 
usually,  but  not  always,  accompanied  by  pain  and  doughy  swelling, 
with  distortion  probably  due  to  the  altered  nerve-supply.  The  process, 
both  pathologically  and  clinically,  differs  markedly  from  tubercular  dis- 
ease.    Suppuration  only  rarely  occurs. 

When  associated  with  hemiplegia,  the  synovitis  is  usually  of  the 
exudative  or  vegetative  type,  and  is  found  especially  in  the  upper 
extremities.  If  associated  with  tabes  the  result  of  trophic  changes  or 
nerve-trunk  disease,  serous  exudate  is  common,  and  the  degenerative 
changes  may  be  so  great  as  to  destroy  the  ligaments  and  permit  the 
most  extraordinary  dislocations ;  or  they  may  result  in  destruction  and 
absorption  of  the  entire  extremity  of  a  bone.1 

Treatment  has  but  little  effect  in  staying  the  course  of  the  disease. 
In  contractions,  downward  traction  by  weight  and  pulley  and  fixation 

1  In  a  shoulder-arthropathy  associated  with  syringomyelia,  Spiller  examined  microscopi- 
cally both  cord  and  spinal  ganglia  with  definite  results  (Am.  Jour.  Med.  Set.,  Dec,  1896). 
The  articulation  was  dislocated,  eroded,  and  surrounded  by  deposits,  and  the  entire  head  of 
the  humerus  had  disappeared.  Some  60  cases  associated  with  syringomyelia  have  been 
recorded,  most  of  them  having  occurred  in  the  upper  extremity. 


NEUROMIMESIS,    OR  HYSTERICAL  JOINT.  "J21 

are  beneficial.     Operative  measures  are  of  use  only  in  relieving  a  false 
position  ;  otherwise  they  are  unnecessary. 


NEUROMIMESIS,  OR  HYSTERICAL  JOINT. 

Nervous  mimicry  of  joint-disease  is  often  difficult  of  diagnosis, 
especially  in  a  patient  who,  from  long  residence  in  a  hospital  or  from 
self-concentration,  has  acquainted  himself  or  herself  with  the  symptoms 
to  be  anticipated  from  an  injury  of  an  articulation.  The  conditions, 
which  at  first  after  traumatism  were  undoubtedly  real  and  positive,  are 
finally  exaggerated  by  the  neurotic,  and  are  mentally  dwelt  upon  until 
absolute  disability  is  developed.  Following  an  injury,  the  first  move- 
ments, after  enforced  rest,  are  necessarily  painful,  and  the  patient  seeks 
to  protect  the  joint;  therefore,  if  a  surgeon  fails  to  differentiate  between 
still  existing  conditions  and  the  pains  produced  by  the  stiffness  from 
slight  adhesions,  his  error  may  result  in  a  permanent  condition  of 
disability. 

In  all  inflammatory  cases  there  is  a  primary  time  for  rest  and  there 
is  a  secondary  time  for  action.  After  the  subsidence  of  a  simple 
inflammation,  massage  and  use  of  the  limb  are  of  the  utmost  impor- 
tance in  producing  a  cure,  while  in  tubercular  infection  the  use  of  the 
limb  must  be  prohibited  for  a  long  period  of  time.  Hence  the  sur- 
geon must  be  most  judicious  and  skilful  in  his  diagnosis. 

Diagnosis  is  often  obscured  by  actual  inflammatory  thickening 
which  usually  surrounds  a  joint  to  a  greater  or  less  degree  after  an 
injury.  In  such  cases  the  character  of  the  patient  and  the  general 
and  local  symptoms  must  be  closely  studied. 

When,  in  the  absence  of  swelling  or  induration,  there  is  excessive 
pain  upon  movement,  and  especially  when  there  is  marked  hyperesthe- 
sia of  the  skin,  even  under  the  gentlest  touch,  a  neurotic  element  may 
be  strongly  suspected.  While  actual  lameness  and  all  subjective 
symptoms  may  be  present,  yet  they  will  be  found  altogether  out  of 
proportion  to  the  actual  palpable  conditions.  By  engaging  the  patient's 
attention  during  the  joint-examination  and  by  close  observation  of  each 
symptom  a  diagnosis  may  be  made,  although  probably  not  at  a  single 
sitting. 

In  cases  of  doubt  anesthesia  may  assist.  In  tubercular  joint-lesion 
muscular  rigidity  will  disappear  late  in  the  process  of  anesthesia,  and 
will  be  renewed  as  soon  as  the  individual  returns  from  the  stage  of 
complete  unconsciousness  ;  while  in  a  hysterical  joint  this  muscular 
protection  will  not  reappear  until  the  individual  is  thoroughly  conver- 
sant of  his  acts. 

The  absence  of  effusion  and  the  atrophy  of  muscles  are  also  impor- 
tant elements  in  diagnosis.  Spinal  tenderness,  nerve-pains,  and  a  gen- 
eral line  of  neuroses  may  assist  in  the  recognition  of  the  true  con- 
dition. 

In  the  treatment  of  neuromimesis  it  should  never  be  forgotten  that 
the  tenderness,  though  aggravated,  is  real.  The  confidence  and  co-op- 
eration of  the  patient  must,  therefore,  be  secured.  This  must  be  fol- 
lowed by  attention  to  the  general  health.  Massage  should  be  used, 
and  mechanical,  passive,  and  active  movements  should  be  employed. 

46 


722 


INTERNATIONAL    TEXTBOOK   OF  SURGERY. 


Superheated  dry  air  and  progressive  voluntary  use  of  the  joint  should 
follow.  Such  a  course,  if  carefully  pursued,  will  result  in  restoring 
function  to  a  joint  which  might  otherwise  become  permanently  disabled. 
Local  blisters  and  the  actual  cautery  arc  often  useful,  together  with 
blistering  of  the  lumbar  spine. 

LOOSE  BODIES  IN  THE  JOINTS;  DISLOCATION  OF  CARTILAGE. 

Loose  or  movable  bodies  in  the  joints,  or  floating  cartilages,  may 
be  entirely  free  or  may  be  partially  restrained  by  pedicles. 

Ecchondromata  are  formed  from  true  cartilage  of  bone,  or  the  sepa- 


FlG.  354. —  Dislocation  of  the  semilunar  cartilage. 


rated  nodosities  of  osteo-arthritis,  or  the  violently  detached  portions  of 
cartilage,  or  from  overgrowths  of  synovial-membrane  cartilage-cells. 
Ecchondromata  are  also  formed  from  the  villous  outgrowths  of  the 
synovial  membrane  which  have  been  gradually  torn  free,  or  from 
degenerated  fibrinous  tuberculous  fringes. 

Symptoms. — The  distinct    symptom  is  a  sudden  pain,  partial  or 


LOOSE   BODIES  IN   THE  JOINTS.  J 2$ 

total  disability,  and  often  a  locking  of  the  joint,  usually  the  knee,  while 
it  is  in  a  flexed  position.  A  synovitis  with  effusion  frequently  results, 
which  slowly  subsides  under  rest,  but  reappears  at  each  repetition  of 
the  accident.  The  bodies  may  often  be  felt  beneath  the  skin,  but 
readily  hide  themselves  in  the  tissues.  I  have  seen  them  one-half  the 
size  of  the  patella,  and  yet  producing  no  serious  trouble. 

The  condition  with  which  this  state  is  most  likely  to  be  confounded 
is  displacement  of  the  semilunar  cartilages  or  "  internal  derangement 
of  a  joint"  (Fig.  354),  a  tearing  loose  of  the  semilunar  cartilages  from 
rupture  of  the  coronary  ligaments.  This  may  be  the  effect  of  injury 
from  sudden  hyperextension,  or  from  flexion  or  rotation,  and  is  accom- 
panied by  severe  pain  and  locking  of  the  articulation. 

Treatment. — Reduction  of  a  joint  locked  from  loose  bodies  is 
usually  readily  accomplished  by  extension  followed  by  forcible  flexion 
and  rotation.  The  ancient  plan  of  strong  flexion  against  the  edge  of  a 
table  upon  which  the  patient  sits  is  a  good  one.  Anesthesia  may  be 
required.  Mechanical  retention  of  the  bodies  by  apparatus  or  elastic 
bandage  is  seldom  successful.  When  locking  is  frequent  and  locomo- 
tion troublesome,  aseptic  removal  of  the  loose  bodies  is  the  only  hope 
of  cure.  If  an  anesthetic  is  given,  the  precaution  of  preliminary  fixation 
of  the  nodule  with  a  tenaculum  or  needle  should  be  adopted. 

Dislocation  of  the  semilunar  cartilages  may  be  reduced  in"  a  similar 
manner.  When  the  cartilages  persistently  slip  from  their  positions,  an 
apparatus  which  will  prevent  rotation  of  the  leg  upon  the  thigh,  check 
the  joint-action  before  full  extension  is  reached,  and  permit  only  flexion 
of  the  knee  will  be  most  helpful.  Should  this  fail,  the  cartilages  them- 
selves should  be  aseptically  excised,  or  moored  to  the  periosteum  by 
silver  sutures. 


CHAPTER    XXI. 


DISEASES  OF  SPECIAL  JOINTS  (ORTHOPEDIC  SURGERY). 

DISEASES  OF  THE  HIP-JOINT. 

Diseases  of  the  hip-joint  are  due  to  changes  in  the  capsule  or  the 
bones,  impairing  the  use  of  the  part.  These  diseases  are  mostly  inflam- 
matory, either  chronic  or  acute ;  by  far  the  most  frequent  is  that  called 
tubercular,  due  to  the  parasitic  action  of  the  tubercle  bacillus,  and  met 
with  on  a  large  scale  in  the  urban  communities  of  temperate  climates. 
Typical  examples  of  this  disease  have  been  familiar  for  centuries,  and 
have  been  termed   morbus   coxse,  coxitis,   or   hip-disease  (Fig.    355). 


FlG.  355. —  Right  hip-disease,  chronic,  in  a  boy  of  nine ;  marked  flexion  and  adduction. 

Inflammation  of  the  hip-joint  may  attend  other  infective  states,  or 
general  disorders  of  the  system,  such  as  pyemia,  osteomyelitis,  gonor- 
rhea, scarlatina,  rheumatism,  rheumatoid  arthritis,  gout,  and  syphilis. 
Occasionally  the  joint  is  affected  by  the  "  simple  inflammation  "  of  an 

724 


DISEASES    OF   THE   HIP-JOINT.  725 

uncomplicated  injury,  such  as  sprain  or  dislocation.  The  existence  of 
these  various  diseases  has  often  been  certified  by  scientific  proofs,  which 
are  sometimes  applicable  in  clinical  practice ;  but  in  many  instances  the 
definition  of  the  actual  variety  of  disease  is  chiefly  a  matter  of  inference 
and  more  or  less  probability.  In  clinical  practice,  many  cases  now 
inferred  to  be  tubercular  are  capable  of  recovery,  and  often  of  complete 
resolution,  under  suitable  mechanical  treatment  and  rest;  and  exact 
proof  of  their  nature  must  often  be  wanting,  though  a  belief  in  the 
character  of  the  disease  is,  with  our  present  knowledge,  irresistible. 

Cause. — It  cannot  always  be  definitely  ascertained  whether  tubercular  hip-disease  is  the 
result  of  injury  or  has  apparently  arisen  "spontaneously;"  but  there  is  every  reason  to 
believe  that  the  disease  sometimes  arises  in  direct  consequence  of  injurv,  while  at  others  it 
may  occur  apparently  without  any  such  contributory  cause.  Tubercular  joint  disease,  espe- 
cially in  children,  often  occurs  in  individuals  seemingly  robust  and  well. 

The  tissues  affected  in  joint-diseases  are  the  capsule  and  the  bones,  and  inflammation 
may  take  the  form  of  "capsular  arthritis,"  of  "  osteo-arthritis,"  or  of  both.  If  fluid  is 
effused  within  the  capsule,  there  is  said  to  be  "synovitis,"  or  inflammation  of  the  synovial 
lining  of  the  capsule.  In  some  cases  the  synovitis  may  attend  osteo-arthritis.  In  a  well- 
defined  exposed  joint,  like  the  knee,  these  distinctions  are  easily  made  out  at  the  bed-side  ; 
but  it  is  different  with  the  hip,  situated  deeply  among  the  muscles.  The  evidences  of  opera- 
tion and  of  post-mortem  examination  make  it  certain  that  in  hip-disease  the  inflammation  may 
attack  the  capsule,  or,  usually  primarily,  the  bones  inside  the  capsule  ;  but  we  have  no  cer- 
tain means  of  deciding  at  the  commencement,  and  had  better  therefore  not  attempt  always  to 
predict  in  which  tissue  the  disease  arises,  seeing  that  some  cases  recover  without  defect  and 
without  trace.  Whether  the  disease  begins  in  the  bones  or  in  the  capsule,  there  may  be 
effusion  of  fluid,  which  can  be  detected,  when  in  sufficient  quantity,  on  one  side  or  other 
of  the  joint.  Such  evidence  of  fluid  apparently  hardly  ever  produces  much  distention  and 
bulging  of  the  capsule,  so  that  the  term  "synovitis"  is  seldom  if  ever  applicable,  in 
the  opinion  of  the  writer,  to  any  of  the  conditions  found  in  this  particular  joint.  The 
thickening  of  and  about  the  joint  is  due  mainly  to  infiltration  of  the  various  tissues. 

Symptoms. — The  symptoms  of  hip-disease  can  best  be  under- 
stood by  studying  those  of  the  most  numerous  class,  the  tubercular, 
and  may  be  comprised  under  three  heads — pain  and  tenderness,  lame- 
ness, and  deformity.  In  a  typical  case  there  are  pain  and  tenderness  in 
the  joint,  which  is  stiffened  in  the  flexed  position,  and  there  is  a  limp 
or  roll  in  the  gait. 

The  symptoms  in  such  a  case  are  sometimes  so  definite,  and  so  obviously  point  to  the 
region  affected,  that  their  proper  cause  is  easily  recognized  by  a  medical  attendant  who  may 
have  little  or  no  previous  experience  to  guide  him.  In  fact,  the  parents  or  friends  of  the 
patient,  or  the  patient  alone,  may  not  infrequently  be  enabled,  in  the  light  of  common 
sense  or  of  local  perception,  to  form  a  good  idea  of  what  is  the  matter.  But,  easy  though  it 
be,  in  typical  cases,  to  recognize  the  affection  when  several  symptoms  point  to  it,  there  is 
uncertainty  when  some,  or  even  most,  of  the  usual  symptoms  are  absent,  unless  the  observer 
has  a  varied  experience  of  his  own,  or  has  rules  laid  down  by  the  experience  of  others. 
The  pain,  for  instance,  may  be  insignificant,  and  even  absent  altogether  ;  while  tenderness 
on  pressure  or  movement  may  be  unnoticeable.  There  is  then  to  be  considered  the  limping 
or  rolling  gait,  which  is  very  conspicuous  when  due  to  pain  or  tenderness,  but  which  is 
often  due  merely  to  stiffness  and  a  fixed  attitude,  mostly  flexion,  when  neither  pain  nor 
tenderness  exists.  In  the  case  of  infants  in  arms  the  gait  cannot  be  tested.  There  then 
remain  the  adoption  of  certain  attitudes  and  the  stiffness  of  the  joint,  which  have  now  to  be 
considered. 

In  examining  a  typical  case  of  hip-disease,  with  pain,  tenderness, 
and  limping,  if  the  patient  is  stripped  and  laid  on  the  floor,  on  a  table, 
or  other  suitable  flat  surface,  there  is  always  found  to  be  a  stiffened 
and  usually  a  more  or  less  flexed  attitude  of  the  limb  on  the  affected 
side.  There  is  a  want  of  symmetry  between  the  lower  limbs  in  some 
positions.    If  the  legs  and  thighs  be  placed  parallel  in  line  with  the  body, 


726 


INTERNATIONAL    TEXT- BOOK   OE  SURGERY. 


there  is  found  to  be  bending  of  the  trunk  by  increased  arching  of  the 
lumbar  spine,  which  thus  cannot  be  brought  into  contact  with  the  sur- 
face on  which  the  patient  is  lying.  If,  however,  the  knees  and  hips  be 
flexed  equally  on  both  sides,  the  lumbar  spine  can  be  flattened  and  the 
trunk   thus   straightened ;    and    if   flexion    be  the   only  deformity,  its 

amount  is  readily  ascertained  and  a 
symmetrical  attitude  found  for  the 
limbs  and  trunk.  Flexion,  how- 
ever, is  not  always  the  sole  position 
in  which  the  joint  is  stiffened,  for 
there  may,  in  addition,  be  abduc- 
tion or  adduction,  or  there  may  be 
rotation  out  (Fig.  356)  or  rotation 
in.  Symmetry  of  the  trunk  is  se- 
cured by  straightening  the  spine 
and  placing  the  anterior  iliac  spines 
on  a  level,  by  adjusting  the  pelvis 
until  the  line  through  the  sternum, 
umbilicus,  and  pubic  symphysis  is 
straight;  symmetry  of  the  limbs  is 
secured  by  flexing  both  knees  and 
hips  as  much  as  is  required  to  ob- 
literate the  abnormal  lumbar  curve, 
and  in  the  event  of  adduction  by 
crossing  the  legs,  in  that  of  abduc- 
tion by  setting  them  apart.  The 
attitude  in  which  the  loin  and  thigh 
are  fixed  on  the  diseased  side  is  thus 
imparted  to  the  unfixed  and  supple 
corresponding  parts  on  the  sound 
side.  All  this  may  appear  some- 
what complicated  in  words,  but  it 
can  be  understood  in  a  few  mo- 
ments at  a  glance,  with  slight  ma- 
nipulations. An  exact  demonstra- 
tion of  the  flexion,  abduction,  ad- 
duction, or  rotation  is  easily  made 
by  adopting  a  device  of  the  late 
Hugh  Owen  Thomas.  This  con- 
sists in  flexing  the  sound  hip  and 
knee  to  the  fullest  extent,  as  the 
patient,  stripped,  lies  on  his  back 
on  a  flat  surface,  holding  the  limb 
in  that  attitude  against  the  chest 
while  putting  the  diseased  limb  as 
straight  as  it  will  go.  The  precise 
amount  of  flexion  or  other  deformity  is  then  displayed  in  the  affected 
hip-joint  (Fig.  357).  Abduction  or  adduction  may  or  may  not  be  pres- 
ent, and  the  same  applies  to  the  rotation  out  or  in.  But  in  every  case  of 
hip-disease  previously  untreated  by  rigid  apparatus  or  by  effective  rest  in  the 
lying  post?/ re,  a  certain  amount  of  stiffness  in  the  flexed  position  is  present. 


Fig.  356. — Left  hip-disease  in  a  man  of 
fifty-seven;  flexion,  adduction,  and  rotation 
outward. 


DISEASES   OF   THE   HIP-JOINT.  J2J- 

Why  should  flexion  or  other  fixed  attitude  be  found  in  hip-disease  ? 
In  a  healthy  state  of  the  parts,  all  the  positions  and  attitudes  of  the  joint 
can  in  turn  be  assumed  at  will ;  but  with  inflammation  come  swelling, 
impairment  of  nutrition  and  function,  and  reflex  spasm,  with  stiffen- 
ing of  the  capsule  and  other  tissues  that  should  be  pliable.  The  stiff- 
ness also  more  or  less  hinders  all  muscular  movement,  especially 
extension,  which  depends  upon  muscular  movement  alone.  Flexion, 
though  also  hindered  by  stiffness  and  muscular  weakness,  is  neverthe- 
less favored  on  every  attempt  at  sitting,  when  the  weight  of  the  body 
alone  tends  to  fold  the  thigh  on  the  trunk.  The  flexion  tends  to  be  con- 
firmed, since  the  joint  never  becomes  perfectly  straightened  in  the  inter- 
vals. Not  only  are  the  muscles,  in  the  stiffened  state  of  the  inflamed 
parts,  less  effective  for  the  usual  movements  of  the  joint,  but  even  in 


Fig.  357. — Acute  left  hip-disease,  before  treatment,  in  a  boy  of  seven.     Degree  of   flexion 
displayed  by  H.  O.  Thomas's  test. 

early  cases,  where  the  capsule  is  still  unaffected,  there  may  be  flexion 
from  muscular  spasm.  Instead  of  resting  between  their  efforts,  as  they 
would  in  a  healthy  state  of  the  parts,  all  the  muscles  around  the  inflamed 
hip-joint  are,  through  the  influence  of  the  nervous  system,  brought  more 
or  less  into  a  state  of  constant  contraction.  This  action  is  mainly  invol- 
untary, but  .there  may  be  a  supplementary  effort  of  the  same  kind  con- 
sciously effected  at  the  instance  of  the  patient's  own  reason  and  expe- 
rience. This  rigid  "  watchfulness  "  of  the  muscles  more  or  less  attains,, 
in  certain  cases,  the  effect  of  partially  warding  off  pain  by  an  attempt  to 
keep  the  joint  still  during  the  waking  state  of  the  patient.  When  the 
patient,  however,  drops  off  to  sleep,  the  muscles  relax  and  the  limb 
moves,  causing  in  the  joint  a  momentary  pain  under  which  the  muscles 
instantly  contract  again,  producing  the  well-known  "  starting  pains." 
This  symptom  was  considered,  and  is  still  by  some  accepted,  as  evi- 
dence of  ulceration  in  the  cartilages.  It  is  not  easy  to  say  how  either 
the  truth  or  the  error  of  such  a  supposition  is  to  be  proved ;  but  the 
explanation  given  above  seems  to  the  writer  more  in  accordance  with 
reason  and  probability. 

Flexion  in  hip-disease  varies  in  degree  from  a  flexion  which  brings 
the  thigh  nearly  in  contact  with  the  trunk  (in  occasional  old  neglected 
cases)  down   to  a  point  where  careful  tests  are  needful  to  demonstrate 


728  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

the  vicious  position.  Usually  the  flexion  is  accompanied  by  adduction 
or  abduction.  Abduction  occurs  sometimes,  especially  in  early  cases, 
but  is  less  common.  Later  the  combination  of  adduction  with  flexion 
is  the  familiar  picture.  No  less  important  than  the  presence  of  deformity 
is  the  limitation  of  motion  by  muscular  spasm  which  may  occur  where 
there  is  no  deformity.  In  very  early  cases  the  only  sign  present  may 
be  a  certain  limitation  of  the  range  of  motion  as  compared  with  that  of 
the  sound  hip.  There  may  be  limitation  of  all  movements,  or  of  some 
only ;  for  instance,  there  may  be  a  loss  of  hyperextension  only,  or  of 
external  rotation  and  abduction.  Any  difference  in  the  range  of 
motion  in  the  two  hips  requires  explanation.  If  there  is  no  other  proc- 
ess found,  it  is  safer  to  assume  that  there  is  joint-trouble  (probably 
tubercular),  to  warn  the  parents  of  the  patient  as  to  the  possibility 
of  serious  trouble,  and  to  treat  the  case  for  the  time  being,  until  a 
definite  diagnosis  is  possible,  as  one  of  probable  hip-disease. 

It  is  to  be  noted  that  flexion-deformity  may  be  a  result  of  structural 
changes,  and  hence  may  not  yield  to  treatment.  The  same  is  true,  to 
some  extent,  of  the  limitation  of  motion  ;  but  in  general  the  limitation 
corresponds  pretty  closely  to  the  acuteness  of  the  disease  (whether  in 
early  or  late  stage),  and  is  therefore  a  better  index  of  effectiveness  of 
treatment  than  is  the  decrease  in  permanent  flexion. 

Since  flexion  is  in  certain  cases  the  only  symptom  upon  which  reliance  can  be  placed 
in  the  diagnosis  of  hip-disease,  it  becomes  important  to  detect  it  with  certainty.  Flexion  is 
found  also  in  caries  of  the  lumbar  spine,  with  abscess  in  the  iliac  fossa.  In  hip-disease 
the  spine  arches  readily  when  the  limb  is  pressed  straight  while  the  patient  lies  on  his  back  ; 
in  spinal  disease,  however,  the  knee  cannot  be  pressed  down,  but  remains  tilted  up,  owing 
to  stiffness  in  the  flexor  muscles  of  the  hip-joint  and  rigidity  of  the  spine.  Such  cases  may 
be  mistaken  for  each  other,  especially  when  attended  with  abscess  in  the  groin  and  iliac  fossa. 

Another  well-known  symptom,  "  flattening  of  the  buttock,"  is  the 
result  of  muscular  wasting ;  and  the  wasting  of  other  muscles  leads  to 
a  general  atrophy  of  the  limbs.  In  certain  muscles  this  is  the  specific 
atrophy  of  joint-disease ;  there  is  also,  however,  the  atrophy  of  disuse, 
affecting  all  the  tissues,  as  seen  in  the  short  foot  familiar  in  old  hip 
cases. 

When  pain  attends  hip-disease,  it  is  commonly  definite,  and  referred 
to  the  immediate  neighborhood  of  the  joint;  but  sometimes  it  is  also 
felt  down  the  front  or  inner  side  of  the  thigh,  and  even  as  far  as  the 
knee.  This  distant  pain  is  supposed  to  be  due  to  irritation  of  the 
obturator  nerve,  the  distribution  of  which  in  the  hip-  and  knee-joints 
and  down  the  thigh  corresponds  with  the  distribution  of  the  pain. 
Even  in  the  absence  of  pain  in  the  hip-joint,  pain  down  the  thigh  or  in 
the  knee  may  be  felt,  and  might  withdraw  the  surgeon's  attention  from 
the  joint  concerned,  were  it  not  that  the  traditional  interest  attached  to 
"  pain  in  the  knee  "  has  become  established,  in  literature  and  practice, 
as  a  symptom  of  hip-disease.  The  pain  accompanying  hip-disease  is 
often  persistent  and  prolonged,  and  even  when  it  has  ceased  to  be 
constant  or  frequent,  is  easily  reproduced  by  slight  movement  or 
pressure.  It  is  probable  that  acuteness  of  pain  in  the  hip-joint  is  a 
sign  of  tension.  This  tension  may  be  intracapsular  or  osseous.  Per- 
sistent and  prolonged  pain,  described  as  dull  aching  or  boring  in 
character,  often  attends  cases  in  which  the  bones  are  primarily  affected, 


DISEASES   OF   THE   H1PJ0IXT.  729 

and  in  which  afterward  shortening  of  the  femoral  neck  or  absorption 
of  the  head  is  manifested  by  the  altered  position  of  the  great  trochanter, 
and  by  a  shortened  limb.  Tension  or  at  least  irritation  in  parts  inflamed 
may  be  brought  about  by  their  movements  ;  hence  the  great  pain  ex- 
perienced in  many  cases  of  inflamed  joint  previous  to  their  fixation  by 
a  suitable  splint,  and  the  converse,  the  early  relief  experienced  on  the 
mechanical  attainment  of  immobility. 

All  this  may  occur  without  abscess,  and  the  result  may  be  a  complete  return  to  sound- 
ness, in  the  sense  of  recovery  from  inflammation,  the  disappearance  of  all  pain  and  tender- 
ness, the  maintenance  of  strength  and  of  a  large  amount  of  mobility.  But  there  may  easily  be 
left  some  flexion-deformity,  and  usually  some  limitation  of  motion,  especially  if  mechanical 
treatment  has  not  been  very  thoroughly  persisted  in  for  a  long  time.  More  generally,  how- 
ever, in  cases  of  prolonged  pain  and  primary  disease  of  the  bones,  an  abscess  forms,  and 
effects  a  great  and  serious  change  in  the  prospects  and  management  of  the  case,  although 
such  an  abscess  may  become  absorbed  quietly,  with  or  without  aspiration. 

The   "  shortening "   alluded  to  as  a   deformity  is  most  important, 
and    always   indicates   defective    growth   or   loss   of  substance   in   the 
femur.     It  may  in  later  stages  be   considerable   in   amount,  and  will 
then  usually  be  found  to  indicate  partial  or  complete  luxation  of  the 
hip,   rendered    possible    especially   by   the   absorption   of  the    rim   of 
the  acetabulum.     Such  luxation  may  occur  despite  careful  treatment. 
There  are,  however,  many  cases  in  which  stiffness  in  the  flexed  position, 
with  or  without  other  fixed  attitudes,  produces  an  effect  of  shortening 
that  on  close  investigation  is  found  to  be  apparent  only.    To  distinguish 
between  "  apparent"  and  "real"  shortening  is  of  importance,  but  this  can- 
not be  attained  by  merely  measuring  the  length  from  the  anterior  pubic 
spine  to  some  fixed  point  in  the  limb,  such  as  the  tip  of  a  malleolus, 
unless  the  relation  of  the  limb  to  the  pelvis  is  the  same  on  both  sides. 
For  ordinary  purposes  the  amount  of  real  shortening,  or  its  absence  in  the 
event  of  apparent  shortening,  can  be  detected  at  a  glance  by  placing  the 
limbs  "  symmetrically,"  as  referred  to  above  in  the  estimation  of  flexion. 
These  adjustments  are  effected  by  manipulating  the  limb  on  the  diseased 
side  until  the  pelvis  is  placed  quite  evenly.    Then  the  sound  limb  is  put  in 
the  same  position  as  that  in  which  the  other  is  fixed,  and  by  comparing 
the  two  sides  their  length  is  found  to  be  identical  in  cases  of  apparent 
shortening,  and  the  amount  of  true  shortening  is  accurately  seen  in 
cases  where  it  exists.     For  exact  measurement,  however,  and  complete 
demonstration,  "  Nelaton's    line "   is   valuable.      This    is   indicated   by 
laying  a  tape  on  the  outer  side  of  the  limb  from  the  anterior  superior 
iliac  spine  to  the  ischial  tuberosity  of  the  same  side.     In  a  sound  hip, 
or  in  one  unaffected  by  shortening,  the  tip  of  the  great  trochanter  lies 
just  below  this  line.     In  the  event  of  shortening,  the  amount  will  be 
shown  by  the  altered  situation  of  the  trochanter  in  relation  to  Nelaton's 
line.     For  this  demonstration  the  patient  has  to  be  turned  over  on  the 
sound  side. 

Diagnosis. — From  the  account  just  given  under  the  head  of 
Symptoms,  it  is  evident  that  the  diagnosis  may  be  easy  or  difficult 
according  to  circumstances.  Many  cases  run  their  course  without 
abscess  or  any  signs  of  liquid  effusion.  Some  are  actually  painful  and 
disabling,  and  attract  attention  early ;  while  others  are  milder  in  their 
course,  and  more  or  less  recovered  from,  even  if  untreated,  and  result 
in  flexion-deformity  and  stiffness.     Mistakes  in  diagnosis  may  be  made 


73Q 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


not  only  by  beginners  but  by  persons  of  ripe  and  varied  experience. 
The  most  usual  mistakes  are  the  confusion  of  hip-  and  spine-disease 
above  referred  to,  the  failure  to  recognize  acute  sprains  or  fractures  of 
the  femoral  neck,  and  occasional  failure  to  detect  congenital  hip-disloca- 
tion or  coxa  vara. 

Principles  of  Treatment. — The  treatment  of  hip-disease  has  the 
following  objects  in  view:  (i)  immobilization  of  the  joint ;  (2)  separation 
by  traction  of  the  joint-surfaces;  (3)  the  correction  of  flexion  or  other 
malposition ;  (4)  the  treatment  of  abscess.  In  early  cases  the  importance 
of  rest  in  bed  must  always  be  kept  in  mind.  Even  if  no  appliances  be 
at  hand,  this  resource  need  never  fail,  especially  in  the  presence  of  pain 
or  tenderness.  Its  employment  is  obviously  dictated  by  common  sense, 
and  cannot  be  dispensed  with  until  all  pain  and  tenderness  are  gone. 
The  application  of  a  splint,  without  confining  the  patient  to  bed,  should 
seldom  or  never  be  resorted  to  until  the  surgeon  has  had  some  experi- 
ence in  its  use,  enabling  him  to  judge  which  cases  are  fitted  to  move 
about  from  the  commencement.  Not  only  in  early  cases,  but  where 
there  is  double  hip-disease,  and  in  cases  at  any  stage  where  there  is 
much  pain  or  tenderness,  marked  deformity  or  rapid  progress,  with  or 
without  abscess,  bed  treatment  is  indicated.  Almost  invariably,  how- 
ever, the  recumbent  position  has  to  be  supplemented  by  some  mechani- 
cal arrangement  that  fixes  the  limb  and  trunk  in  line.  The  more 
completely  and  rigidly  this  fixation  is  attained,  the  more  effectual  will 
the  treatment  be.  For  this  purpose  the  long  splint  of  Liston  has  often 
served,  and  up  to  about  1874  was  the  chief  resource  in  the  British  Isles. 

In  the  case  of  infants  the  single  long  splint  is  almost  useless,  because 
the  patient  rolls  over  on  the  side,  in  which  position  flexion  of  the  hip- 
joint  is  not  prevented.  To  secure  proper  immobility,  a  pair  of  long 
splints  attached  by  a  cross  bar  at  each  end,  so  as  to  constitute  a  stiff 
frame,  keeps  the  patient  still  enough  to  attain  the  object  in  certain  cases. 
Still  better  is  a  fixation-frame  to  which  the  patient  may  be  strapped. 
Such  a  frame  may  be  made  of  light  gas-pipe,  joined  at  the  corners  with 


FIG.  358. — Bradford's  fixation-frame. 


ordinary  right-angled  gas-fitters'  joints.  It  should  be  from  two  to  four 
inches  longer  than  the  patient,  of  a  width  about  equal  to  that  between 
the  shoulder-tips.  It  is  covered  with  stout  drilling,  tightly  stretched, 
as  shown  in  the  illustration  (Fig.  358).  Such  a  frame  gives  a  means 
of  fixation  for  the  patient's  body,  and  makes  it  possible  to  move  him 
without  stirring  up  the  joint.  Traction  is  applied  by  weight  and  pul- 
ley ;  a  hold  on  the  limb  is  secured  by  adhesive  plaster  strips  running 


DISEASES   OF  THE  HIP-JOINT. 


731 


well  up  the  thigh  ;  the  weight  used  is  from  4  to  10  pounds.  Trac- 
tion is  made  in  the  line  of  deformity,  if  deformity  is  present ;  if  flex- 
ion is  present,  the  leg  is  meanwhile  supported  on  an  inclined  plane. 
Under  this  treatment  reflex  spasm,  the  usual  cause  of  deformity,  re- 
laxes, and  the  apparatus  is  gradually  lowered  till  the  traction  is  exerted 
in  full  extension. 

The  Thomas  hip-splint  is  also  used  for  bed  treatment,  though  it 
does  not  in  its  usual  form  provide  for  traction. 

The  great  mechanical  value  of  Thomas's  hip-splint  rests  in  its  applica- 
tion behind  the  limb  and  the  trunk,  in  such  a  way  as  most  effectually  to 
oppose  all  tendency  to  flexion  (see 
Figs.  270,  277).  It  is  made  of  flat 
iron  rod  stiff  enough  to  resist  the 
muscles  of  the  patient,  but  not  too 
stiff  to  be  twisted  or  bent  forcibly 
by  the  surgeon  or  instrument- 
maker.  In  its  single  form  it  is 
slightly  padded  and  covered  with 
leather  (Fig.  359).  For  infants  and 
young  children  the  double  splint 
is  much  the  best,  and  fixed  pad- 


FlG.  359. — Thomas's  single  hip-splint. 


FlG.  360. — Thomas's  double  hip-splint  ready 
for  application  ;  loose  pad  for  the  back  in  situ  ; 
shoulder-braces  of  bandage  passing  through 
leather  tubes  to  go  over  the  shoulders. 


ding  can  often  be  dispensed  with,  being  replaced  by  a  large,  loose  flat 
pad  enclosed  in  basil  leather  for  the  back  (Fig.  360),  while  the  limbs 
are  protected  by  a  roll  of  cotton  wadding  bandaged  on.  The  modifi- 
cation of  the  Thomas  splint  by  Robert  Jones  (Fig.  362)  provides  not 
only  for  fixation,  but  for  traction  as  well,  and  a  certain  amount  of  ab- 
duction counteracting  the  usual  adduction  and  flexion-deformity. 

The  vast  majority  of  cases  of  hip-disease,  however,  need  bed  treat- 
ment for  a  short  time  only,  or  at  infrequent  intervals,  and  can  be  well 


732 


INTERNATIONAL    TENT- BOOK   OF  SURGERY. 


treated  by  ambulatory  splints  (see  Fig.  277).  The  first  requisite  of  such 
a  splint  is  that  it  relieve  the  hip  of  weight ;  the  second,  that  it  fix  the 
hip.  Beyond  this  there  is  good  reason  to  believe  traction  on  the  leg  of 
definite  value.  The  splints  most  in  use  are  modifications  of  those  of 
Thomas  and  of  Taylor.  The  Thomas  splint  is  more  effective  in  fixing 
the  joint  and  limiting  flexion.  [It  is,  however,  somewhat  cumbersome, 
does  not  afford  any  traction  beyond  the  weight  of  the  limb,  and  does 
not  really  insure  rest  to  the  hip  even  where  a  high  sole  on  the  other 
foot  is  used,  for  children  are  very  likely,  where  the  joint  is  not  tender, 


Fig.  361. — A,  Long  traction-splint;  B,  Convalescent  splint. — ED. 


to  use  the  foot  despite  any  apparatus.  The  Taylor  splint  fixes  less 
well,  but  with  proper  application  it  is  possible  to  secure  good  traction 
and  to  prevent  absolutely  any  use  of  the  limb.  With  either  splint  the 
high  sole  and  crutches  should  be  used. — Ed.] 

If  pain  persists  in  spite  of  a  well-applied  splint,  it  will  be  due  to  a 
persistent  course  of  the  disease,  especially  in  the  bones. 

In  late  cases,  if  the  flexion  is  great  and  the  stiffness  is  marked, 
though  not  extreme,  while  pain  is  absent,  and  the  case  is  chiefly  one 
of  deformed  attitude  and  resulting  chronic  lameness,  rest  in  bed,  with 
traction  and  prolonged  treatment  with  the  extension-splint,  will  effect 


DISEASES   OF  THE  HIP-JOINT. 


733 


a  gradual  straightening,  and  ultimately  greatly  improved  progression. 
This  gradual  straightening  is  a  spontaneous  process  unattended  by  any 
mechanical  force  on  the  part  of  the  surgeon,  who  merely  "  takes  in  the 
slack  "  as  he  finds  it.  It  is  not  always  painless,  and  may  be  a  source 
of  much  aching  and  sleeplessness  to  the  patient  during  the  first  few 
i days.  This  pain  is  due  to  the  stretching  of  muscles  which  have  become 
shortened  during  the  maintenance  of  the  flexed  attitude,  and  also,  per- 
haps, to  a  similar  stretching  of  shortened  capsule. 

A  very  important  question  then  arises  as  to  how  long  treatment 
must  be  continued.  It  must  be  obvious  that  treatment  should  con- 
tinue until  the  symptoms  have  disappeared  and  do  not  return  ;  but  the 
symptoms  sometimes  do  return  shortly 
after  remitting  the  treatment.  Practi- 
cally, it  is  not  safe  to  omit  the  splint 
until  a  year  or  two  after  muscular 
spasm  has  disappeared.  [During  this 
period,  however,  a  convalescent  splint 
(Fig.  36 1 ,  B)  may  be  worn. — Ed.]  After 
the  application  of  such  splint  the  patient 
should  be  carefully  inspected  at  inter- 
vals, to  see  whether  any  flexion-stiff- 
ness, pain,  or  increased  tenderness  has 
returned.  The  return  of  any  symptom 
should  be  met  by  the  re-application  of 
the  splint  previously  worn,  or  perhaps 
by  confinement  to  bed,  and  treatment 
is  to  be  continued  until  all  symptoms 
are  gone  and  fail  to  return  before  re- 
suming the  convalescent  splint.  The 
removal  of  the  splint  becomes  just  as 
much  a  matter  of  experience  as  its 
original  application.  The  evidence  of 
complete  resolution  is  the  absence  not 
only  of  all  pain  and  tenderness,  but 
also  of  all  stiffness  or  return  of  de- 
formity. The  patient  must  be  able  to 
extend  the  hip-joint  fully  while  lying 
down  on  a  flat  surface  with  the  sound 
limb  bent  completely  on  the  trunk.  In 
practice,   however,   perfect   results   are 

rare.  After  a  prolonged  adoption  of  the  straight  position  in  the  splint, 
and  the  increase  and  improvement  of  locomotion  this  affords,  one  of 
two  things  may  be  expected  to  result — either  the  occurrence  of  perma- 
nent stiffness  in  the  straight  attitude,  or  the  restoration  of  movement 
in  the  joint.  The  permanent  stiffness  of  the  hip-joint  either  by  bony 
ankylosis,  which  is  not  frequent,  or  by  fibrous  adhesion  affords,  when 
attended  by  the  straight  position,  a  complete  and  almost  perfect  loco- 
motion, which  in  walking  can  be  effected  without  the  slightest  limp,  if 
there  be  no  shortening.  If  in  treating  a  case  no  relaxation  of  the 
flexion  occurs,  if  bony  ankylosis  be  otherwise  ascertained  to  exist,  the 
femur  may  be  divided  at  or  above  the  great  trochanter. 


Fig.  362. — Thomas's  double  hip- 
splint  as  modified  for  extension  and 
abduction  on  the  left  side ;  perineal 
band  on  the  right. 


734  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

The  ideal  treatment  of  abscess  with  accompanying  hip-disease 
would  naturally  be  aseptic  incision,  with  or  without  flushing  with  hot 
water  or  weak  antiseptic  solutions,  and  with  or  without  immediate  su- 
ture after  filling  the  cavity  with  iodoform-and-glycerin  emulsion.  Such 
treatment  should  be  preceded  by  the  application  of  a  splint,  in  com- 
bination with  which  the  necessary  dressings  can  be  applied.  Incision 
of  abscess  requires  bed  treatment  for  some  time  afterward  for  best 
results. 

The  opening  and  satisfactory  healing  of  abscesses  by  aseptic  incision 
and  dressing,  without  removal  of  bone,  may  result  in  all  that  can 
be  desired,  leaving  the  limb  useful  and  unshortened,  as  in  resolution  of 


FlG.  363. — Left  hip-disease  following  typhoid  in  a  man  aged  thirty-six.     Put  up  under  extension 
and  abduction,  after  osteotomy  of  the  neck  of  the  femur. 

the  disease  without  abscess.  If  bony  ankylosis  or  stiff  fibrous  union 
result  in  the  straight  position,  the  necessary  movements  occur  through 
the  flexibility  of  the  lumbar  spine.  Similarly,  the  spontaneous  burst- 
ing of  abscess,  and  even  the  continuance  of  sinuses,  may  result  in  spon- 
taneous healing,  with  or  without  shortening,  flexion,  or  other  deformity. 
But  such  sinuses  may  persist,  and  impair  the  health  or  lame  the  patient. 
Secondary  excision,  performed  from  the  front,  may  result  beneficially, 
and  after  healing  may  be  followed  by  complete  recovery  of  health  and 
strength,  with  shortening,  but  often  with  considerable  motion. 

Although  pain,  tenderness,  and  stiffness  quickly  disappear  in  many 
cases  on  the  application  of  the  splint,  there  are  others,  more  or  less 
acute,  in  which  the  expected  relief  is  greatly  delayed  or  fails  to  occur, 


DISEASES   OF   THE   HIP-JOINT. 


735 


the  case  going  on  from  bad  to  worse.  The  advance  of  the  tubercular 
process  often  accounts  for  this,  and  the  subsequent  shortening  in  cases 
that  eventually  get  well  proves  the  fact  of  absorption  in  the  head  or 
neck  of  the  femur.  In  other  cases  that  have  still  recovered  with 
shortening,  abscess  has  formed  and  has  been  successfully  treated,  the 
process  never  having  been  acute.  Others,  again,  had  early  persistent 
pain,  eventual  relief,  the  late  formation  of  abscess,  and  its  successful 
aspiration. 

Excision  of  the  joint  is  best  done  at  the  front  or  side,  which  is  more 
accessible  for  dressing  purposes,  while  the  tissues  behind  are  preserved 


FIG.  364. — Multiple  osteomyelitis,  that  of  the  femur  affecting  the  hip-joint;  ten  years' 
duration  ;  patient  aged  sixteen. 

unwounded  for  the  application  of  the  splint.  When  undertaken  com- 
paratively early,  before  the  surface  has  broken,  the  tubercular  process 
has  a  good  chance  of  being  eradicated,  and  the  part  restored  to  sound- 
ness and  utility  more  speedily  than  after  the  formation  of  sinuses. 
There  is  necessarily  some  deformity,  owing  to  the  inevitable  shortening. 
The  pathological  condition  in  the  cases  to  which  early  primary 
excision  is  applied  differs  considerably  from  that  in  which  the  operation 
is  performed  "  secondarily."     In  the  former  class  of  cases  there  is  the 


736  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

unbroken  surface,  and  the  chief  features  of  disease  are  the  softened, 
carious,  and  caseous  state  of  the  cancellous  bone  in  the  head  and  neck 
of  the  femur,  and  the  swollen  and  shreddy  condition  of  the  surrounding 
capsular  ligaments  and  other  soft  parts.  There  may  be  abscess,  but  it 
is  often  more  serous  than  purulent  in  character.  The  object  of  every  such 
operation  is  to  remove  all  tubercular  material,  inflammatory  exudation, 
and  portions  of  devitalized  or  half  nourished  tissues  adjacent,  the 
removal  of  which  by  absorption  is  not,  indeed,  always  impossible,  for 
such  process  must  often  occur,  but  the  presence  of  which  at  the  best 
greatly  delays  the  reparative  process,  and  in  the  event  of  bursting  or 
incision  may  be  attended  with  burrowing  sinuses  and  secondary  infective 
suppuration.  Firmer  and  sounder  tissues  are  left  in  contact  with  each 
other,  and  in  spite  of  the  deformity  resulting  from  removal  of  bone,  a 
much  quicker  local  repair  is  obtained  than  by  the  efforts  of  nature, 
while  the  patient's  health  is  speedily  restored,  or  often  not  actually 
impaired.  Moreover,  the  healing  of  the  parts  sometimes  results  with- 
out suppuration,  febrile  reaction,  or  delay  of  any  kind. 

In  the  cases  to  which  "  secondary  excision  "  is  applied  there  may 
have  been  partial  repair,  but  sinuses  are  established  leading  to  the 
remains  of  the  joint,  and  perhaps  to  the  surface  or  interior  of  carious 
bone.  In  other  cases  steady  increase  of  symptoms  despite  careful 
treatment  is  the  indication  for  excision.  The  object  of  excision  is  to 
open  up  the  burrowing  channels  of  local  infection,  and  to  attain  healing 
by  the  granulation  of  the  cavity  that  remains.  The  effect  of  operation 
in  some  cases  is  as  speedily  beneficial  as  in  the  removal  of  diseased  bone 
in  other  parts  away  from  joints  ;  but  in  other  cases,  where  the  operation 
is  performed  on  emaciated  and  anemic  subjects,  the  risks  are  great 
though  necessary    and  the  recovery  is  sometimes  slow. 

Late  excision  is  indicated  by  the  condition  of  the  joint  per  se,  early 
excision  often  in  adults,  and  where  thorough  treatment  is  impossible. 
The  question  of  the  selection  of  cases  for  early  excision  is  still  a  dis- 
puted point.  Some  surgeons  frequently  employ  this  measure ;  others, 
almost  never.  In  certain  cases  where  the  whole  hip  region  is  involved 
and  riddled  with  sinuses,  especially  where  there  is  an  extensive  osteo- 
myelitis of  the  shaft  of  the  femur,  amputation  is  indicated.  Excellent 
as  the  results  of  late  excision  often  are,  in  some  cases  the  operation  is 
wholly  unsatisfactory. 

In  cases  of  chronic  deformity  attende'd  with  much  shortening,  flexion,  and  adduction, 
with  up-tilted  pelvis,  Robert  Jones  has  still  further  improved  the  treatment  by  action  of  the 
combined  hip-  and  knee-splints,  modified  as  in  the  extension  treatment  of  quickly  deterio- 
rating early  hip-disease.  With  a  fine  saw  he  performs  antiseptic  osteotomy  of  the  femoral 
shaft  very  obliquely  about  the  great  trochanter,  and  then  puts  up  the  limb  in  the  abducted 
position,  under  extension,  during  the  progress  of  union.  As  in  early  caries,  the  extension 
is  maintained,  and  occasionally  re-adjusted,  until  the  limb  is  firm  and  strong.  The  effect  of 
the  abducted  position  is  to  tilt  the  pelvis  down  on  that  side,  and  so  to  make  up  for  some  of 
the  shortening  previously  existing. 

In  November,  1897,  the  writer  succeeded  admirably  in  such  a  case  in  a  man  of  thirty-six, 
much  deformed  after  typhoid.  The  left  hip  was  ankylosed,  adducted,  flexed,  and  rotated 
in,  the  skin  fortunately  being  unbroken,  and  the  tissues  healthy.  Osteotomy  of  the  femoral 
neck  was  performed  with  a  chisel  driven  straight  through  the  skin  above  and  behind.  The 
limb  was  put  up  under  extension  and  abduction.  The  wound  healed  by  first  intention,  and 
all  deformity  was  got  rid  of  in  a  very  few  weeks,  without  impairing  the  patient's  health  in 
the  least.  In  this  case  no  special  appliance  was  used.  The  sound  side  was  fixed  in  an 
ordinary  single  hip-splint.  Extension  was  applied  after  osteotomy  on  the  affected  side  by 
means  of  a  Thomas's  knee-splint.      Abduction  was  kept  up  by  means  of  a  small  knee-splint 


DISEASES   OF   THE   KXEE-JOINTS  737 

tied  to  both  ankles,  so  as  to  keep  them  apart.  The  accompanying  illustration  (Fig.  363) 
is  from  a  photograph  taken  after  seven  weeks,  previous  to  letting  the  patient  up  in  a  left 
single  hip-splint.      He  has  progressed  well  ever  since,  and  all  deformity  is  gone. 

Where  there  is  flexion-ankylosis  or  flexion  with  adduction,  the  sub- 
trochanteric osteotomy  of  Gant  is  also  of  service.  Osteotomy  of  what- 
ever description  is  rarely  to  be  applied  except  in  cases  where  there  is 
firm  ankylosis ;  other  cases  are  usually  more  amenable  to  other  treat- 
ment, either  conservative  treatment  or  excision. 

Osteomyelitis  is  sometimes  a  cause  of  hip-disease,  as  well  as  disease 
of  other  joints  (see  Fig.  364). 

Simple  traumatic  inflammation  of  the  hip  may  occur.  The  treat- 
ment in  Thomas's  splint  is  both  simple  and  speedy,  resulting  in  com- 
plete recovery  in  a  very  few  weeks. 

DISEASES  OF  THE  KNEE-JOINT. 

Affections  of  the  knee-joint  are  chiefly  inflammatory,  and  may  be 
anatomically  divided  into  three  classes:  1.  Synovitis;  2.  Capsular 
arthritis  ;   3.  Osteo-arthritis. 

Synovitis. — By  synovitis  is  usually  understood  an  effusion,  more 
or  less  liquid,  into  the  joint-cavity.  The  effusion  may  be  pure  blood, 
serum,  or  pus.  Since  pneumatic  aspiration  with  antiseptic  precautions 
has  come  into  vogue,  the  nature  of  the  effusion  can  be  harmlessly  and 
often  beneficially  investigated.  Effusions  of  blood  are  commonly 
entirely  liquid,  but  sometimes  coagulate  shortly  after  issuing.  Effu- 
sions of  serum,  so-called,  also  frequently  undergo  partial  coagulation 
of  thin,  yellowish  fibrin.  Effusions  of  pus,  promptly  withdrawn  by 
aspiration,  after  efficient  fixation  in  the  straight  line,  are  sometimes 
cured  after  one  or  more,  sometimes  very  few,  tappings.  The  bac- 
teriological examination  of  the  pus  shows  micrococci,  indicating  the 
character  of  the  inflammation,  which  may  be  pyemic  or  gonorrheal. 
The  differential  study  of  these  conditions  is  favored,  and  the  treatment 
often  expedited,  by  merely  tapping  ;  in  fact,  much  clinical  light  is  thrown 
upon  the  effusions  into  the  knee  by  tapping.  In  aspirating  joints  the  trocar 
should  not  be  smaller  than  a  No.  2  or  3  catheter  (English  scale),  and  may 
be  required  as  large  as  a  No.  4  or  5  or  larger  for  some  purposes.  Effu- 
sions into  the  knee  are  easily  seen  and  felt  by  the  bulging  of  the  joint- 
cavity,  everywhere  in  some  cases,  but  frequently  in  the  suprapatellar 
region  alone.  This  condition  may  exist  without  severe  symptoms,  com- 
ing on  gradually  and  almost  imperceptibly  at  times,  and  then  causing 
no  more  inconvenience  than  a  weakening  of  the  knee  and  diminished 
activity  of  the  limb  ;  but  in  other  cases  severe  pain  and  total  disable- 
ment are  conspicuous,  with  or  without  acute  fever.  Synovitis  may  be 
caused  by  a  sprain,  when  it  may  come  on  immediately  or  after  a  few 
hours,  by  acute  or  chronic  rheumatism,  gonorrheal  rheumatism,  or 
tubercular  inflammation.  It  may  also  be  set  up  by  the  irritation  due 
to  popliteal  aneurysm.  When  resulting  from  sprain  or  other  sudden 
injury,  the  fluid  effused  may  be  pure  blood,  but  is  usually  serous.  The 
joint  in  synovitis  may  or  may  not  be  painful,  tender,  and  disabled,  and 
the  patella  separated  from  the  femur  by  effusion. 

Many  cases  of  synovitis  of  the  knee  tend  to  recur  persistently,  even 
47 


738  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

where  they  cannot  fairly  be  called  chronic.  In  some  of  these  cases 
the  underlying  condition  is  a  stretched  capsule  resulting  from  the  first 
attack,  often  associated  with  a  lack  of  support  from  muscles  which 
have  never  recovered  fully  from  the  atrophy  occurring  with  even  acute 
synovitis.  In  other  cases  a  slipping  patella  is  the  cause,  and  calls  for 
appropriate  treatment,  either  by  protective  apparatus  or,  if  obstinate, 
by  an  operation  to  take  up  slack  on  the  inner  side  of  the  capsule.  In 
other  cases,  however,  more  common  than  either  of  these  conditions, 
we  have  to  deal  with  luxations  of  the  semilunar  cartilages.  This  con- 
dition is  important,  not  only  from  its  relatively  common  occurrence, 
but  from  the  frequency  with  which  it  is  overlooked.  In  a  knee  where 
either  cartilage  has  once  been  luxated  a  slipping  may  occur  on  the  slight- 
est provocation,  and  may  give  rise  to  severe  synovitis.  If  the  cartilage 
be  still  displaced  (evidenced  by  a  painful  "  locking  "  of  the  knee  when 
full  extension  is  attempted),  it  is  possible  to  reduce  it  by  the  classical 
method :  flexion  and  traction,  rotation  and  extension  ;  but  even  after 
entire  subsidence  of  the  acute  symptoms  the  trouble  is  likely  to  recur, 
and  may  eventually  necessitate  removal  of  the  offending  cartilage. 

Some  cases  of  synovial  effusion  are  apparently  of  syphilitic  origin. 
It  has  been  asserted  that  "  symmetrical  synovitis  "  of  the  knees  in 
young  persons  is  often  to  be  accepted  as  evidence  of  inherited  syphilis. 
Be  this  as  it  may,  the  writer  has  met  with  obstinate  synovitis  where  a 
history  of  syphilis  has  existed,  and  where  thickening  of  the  capsule 
and  chronic  orchitis,  suggestive  of  gummatous  enlargement,  have 
yielded  to  antisyphilitic  medication.  The  evidences  of  syphilis  in 
cases  of  synovitis  are,  in  the  opinion  and  experience  of  the  writer, 
both  rare  and  difficult  to  prove ;  but  they  would  appear  at  any  rate 
to  be  met  with  occasionally. 

Attacks  of  synovitis,  with  or  without  the  thickening  that  indicates 
general  capsular  arthritis,  are  not  infrequently  found  associated  with  a 
present  gonorrhea  or  gleet,  or  a  history  of  a  recent  attack.  Such  cases 
well  fixed  in  a  proper  splint  may  be  rapidly  relieved,  but  if  not,  it  is 
well  to  perform  aspiration  after  fixing  the  limb.  If  the  temperature  is 
raised,  suppuration  may  be  suspected,  and  by  this  operation  readily 
found.  The  number  of  tappings  depends  upon  the  effect.  One,  two, 
or  three,  at  intervals  of  twenty-four  or  forty-eight  hours,  or  of  several 
days,  will  commonly  suffice.  The  urethral  discharge  meanwhile  should 
be  treated.  Gonorrheal  synovitis  of  the  knee  is  highly  amenable  to  tap- 
ping, and  commonly  recovers  quickly;  but  the  prognosis  must  always 
be  guarded,  as  fibrous  ankylosis  may  sometimes  occur  in  spite  of  all 
treatment.     Incision  and  joint-irrigation  have  given  some  good  results. 

In  treating  a  case  of  synovitis  it  is  important  to  keep  the  limb  rigid  and 
straight.  A  conventional  method  which  is  not  infrequently  resorted  to 
consists  in  ordering  the  patient  to  bed  and  directing  the  application  of 
fomentations  until  the  pain  ceases  or  recovery  ensues.  This  method  is 
often  a  sheer  waste  of  time,  and,  moreover,  by  delay  aggravates  an  acute 
and  often  quickly  curable  synovitis  into  a  subacute  or  indolent  chronic 
condition.  There  are  cases  of  a  rheumatic  or  gouty  character  in  which 
fresh  air,  exercise,  frugal  feeding,  and  perhaps  local  massage  are  of 
importance,  while  the  fixation  of  the  joint  is  not.  Ordinarily,  fixation 
on  a  splint,  with  some  compression,  is  necessary. 


DISEASES   OF   THE   KNEE-JOINT. 


739 


As  regards  the  splint,  the  most  effectual  of  all  is  Thomas's  knee- 
spiint  made  of  iron  rod.  The  variety  known  as  "bed-splint"  is  appli- 
cable to  either  limb,  having  a  symmetrical  padded  oval  ring  embracing 
the  top  of  the  thigh,  and  a  bar  down  each  side  of  the  limb,  extending 
below  the  foot,  where  the  bars  are  connected.  For  patients  walking 
about,  the  splint  is  made  shorter  and  the  side  bars  are  disconnected 
below,  but  each  is  turned  toward  its  fellow  and  made  to  clip  in  a  hole 
in  the  heel  of  the  boot.  In  that  form  it  is  called  the  "  calliper." 
Another  form  of  "  walking  splint "  (Fig.  365  ]  is  slightly  different  from 
each  of  these  in  its  lower  end,  which 
projects  beyond  the  foot  and  ends  in  a 
"  patten "  or  ring  which  rests  on  the 
ground.  Attached  to  the  boot  on  the 
sound  side  is  another  patten,  to  equalize 
the  length  of  the  two  limbs.  In  this 
fashion  children  and  young  people  can 
walk  without  bearing  any  weight  on  the 
diseased  limb,  which  hangs  suspended 
in  the  iron  frame  that  bears  the  weight, 
as  the  patient  sits  on  the  upper  oval 
ring.  In  severe  and  many  other  cases 
the  use  of  Thomas's  splint  in  one  form 
or  the  other  enables  the  surgeon  to  suc- 
ceed where  otherwise  the  joint  would 
go  on  to  destruction.  In  simple  trau- 
matic cases  a  simple  knee-splint  will 
suffice. 

Where  the  tenderness  and  disable- 
ment are  not  great,  and  the  patient  can 
be  made  to  understand  the  utility  and 
importance  of  voluntarily  keeping  the 
limb  stiff  and  straight,  the  joint  may  be 
fixed  with  wide  strapping  from  the  mid- 
dle of  the  calf  to  the  middle  of  the  thigh. 

For  this  purpose  also  sheets  of  brown  paper 
spread  with  a  mixture  of  pitch  and  resin,  thinned 
with  benzolin,  make  very  useful  plastering  material, 
which  can  be  applied  in  strips  from  3  to  5  inches 
wide.  The  result  is  an  adhesive,  firm,  light  casing, 
having  a  neat  exterior,  that  can  be  readily  torn  off 
when  changed  or  discontinued. 

Capsular  Arthritis. — Capsular  ar- 
thritis is  a  general  inflammation  of  the 
capsule,  and  may  occur  in  cases  of  sprain 
or  other  injury,  with  or  without  synovial 
effusion.  The  peculiarity  about  capsular 
arthritis  is  that  evidently  the  capsule  is 
affected  by  the  inflammation  and  is 
thickened  thereby,  whereas  in  synovitis 
there  is  effusion  without  such  participa- 
tion and  thickening.  Tubercular  arthritis  is 
though    practically   always   the    primary   focus 


FlG.  365. —  Photograph  made  for  H. 
O.  Thomas  in  1875,  showing  his  knee- 
splint  with  square  end.  Compensating 
patten  on  opposite  foot.  The  "  patten 
end  "  of  the  splint  has  been  used  since 
that  date. 


usually   of  this    kind, 
is   in   the   bones.      In 


740  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

some  cases  a  swelling  occurs  in  some  corner  of  the  joint,  protruding 
the  skin,  and  giving  to  the  finger  a  feeling  of  elasticity,  so  much  so 
that  aspiration  or  incision  may  be  practised  in  the  hope  of  letting  out 
fluid,  sometimes  with  and  at  other  times  without  such  issue.  Ana- 
tomical and  surgical  experience  show  that  in  tubercular  infection  there 
may  be  any  degree  of  local  or  general  edema,  puffiness,  swelling,  in 
the  depths  of  which  may  be  miliary  tubercles,  gelatinous  edema,  granu- 
lation tissue,  patches  of  necrotic  caseation,  or  suppuration.  Such 
swelling  often  comes  on  slowly,  painlessly,  and  without  the  collective 
attributes  of  acute  inflammation,  for  which  reason  no  doubt  the  old 
term   "white  swelling"   was   naturally  applied   to  it. 

Treatment. — A  case  of  early  arthritis  of  this  kind  may  sometimes 
rapidly  improve  if  the  joint  be  fixed  and  the  patient's  weight  be  taken 
off  it  by  the  use  of  the  longer  walking  splint  with  patten  end  and  addi- 
tional short  patten  on  the  opposite  foot.  The  need  for  careful  fixation 
by  Thomas's  splint  is  indicated  in  capsular  arthritis,  which  itself  may 
come  on  in  aggravated  synovitis  that  does  not  yield  at  first  to  treat- 
ment. After  recovery  and  discontinuance  of  the  splint,  synovitis  may 
occur  in  the  joint,  and  disappear  again  on  resuming  the  splint.  Some- 
times the  inflammation  is  "  gummatous,"  and  will  yield  to  rest  and  mer- 
curial medication  with  or  without  potassium  iodid  ;  it  may  be  added, 
with  or  without  a  splint. 

Osteoarthritis. — "  Osteo-arthritis  "  or  "articular  osteitis  "  occurs 
in  the  tubercular  process  which  first  affects  the  growing  ends  of 
bone  and  then  implicates  the  adjacent  joint.  There  may  be  con- 
tinuous dull  or  even  severe  pain  in  the  affected  bone,  and  abscess 
may  form  outside  or  may  invade  the  joint.  Osteo-arthritis  may  also 
occur  in  association  with  acute,  and  especially  with  chronic,  osteomye- 
litis, the  latter  of  which,  from  its  slow  and  often  painless  progress,  may 
closely  simulate  the  appearances  of  tubercle  (see  Fig.  366). 

Tumor. — The  existence  of  sarcomatous  "  tumor  "  in  the  interior  of 
the  femur  or  tibia,  at  the  knee,  may  be  attended  with  a  similar  aching 
that  is  indistinguishable  from  that  of  osteitis,  in  both  of  which  diseases 
there  may  be  no  alteration  in  size  during  the  period  of  observation.  In 
other  cases  of  tumors  that  give  way  and  burst  into  the  joint,  there  may 
be  many  of  the  appearances  of  chronic  white  swelling.  The  very  relief 
afforded  by  Thomas's  splint  to  a  patient  still  walking  about  has  been 
known  to  mask  a  case  of  malignant  central  tumor  of  the  femoral  con- 
dyles, where  only  intense  aching  pointed  to  the  great  probability  of  a 
central  disease  of  the  bone.  But  the  disease  is  supposed  to  be  osteitis, 
and  is  only  discovered  to  be  sarcoma  on  performing  excision  of  the  end 
of  the  bone.  In  a  case  left  to  go  about  and  bear  weight  on  the  affected 
bone,  fracture  of  the  bone  and  rapid  diffusion  of  the  tumor  in  and  about 
the  knee-joint  usually  occur  at  an  early  period.  Such  cases  may  be 
recognized  by  the  absence  of  tubercular  history  or  tendency,  by  the 
occasional  existence  of  pulsation  in  the  swelling,  or  by  the  sudden  giving 
way  of  the  limb  on  exertion,  indicating  fracture  of  the  adjacent  bone  in 
cases  where  that  event  occurs.  In  either  tubercular  arthritis  or  tumor 
of  the  knee-joint  there  may  be  antecedent  injury  or  the  reverse,  and 
the  resemblance  between  the  two  conditions  may  be  quite  sufficient  to 
cause  perplexity,  especially  where,  in  the  case  of  tumor,  the  region  is 


DISEASES   OF   THE  KNEE-JOINT.  741 

symmetrical  and  oval,  as  in  typical  white  swelling.  The  conditions  are 
most  apt  to  be  confounded  when  the  likelihood  of  tumor  is  overlooked, 
so  that  a  careful  analysis  of  the  conditions  will  commonly  result  in  a 
correct  diagnosis. 

Treatment  of  Knee-joint  Disease. — The  treatment  should  be 
mechanical  in  the  vast  majority  of  conditions.  In  synovitis,  whatever 
be  the  cause,  mechanical  treatment  is  called  for  at  once.  If  acute  and 
disabling,  the  patient  must  be  kept  in  bed.  In  the  absence  of  the  best 
kind  of  splint,  excellent  fixation  may  be  attained  in  bed  by  a  variety  of 
temporary  expedients,  such  as  canes,  strips  of  wood,  or  other  articles 
of  sufficient  length,  firmly  bound  to  the  limb  over  a  suitable  padding 
of  cotton  wadding  or  thickly  folded  sheeting.  Such  temporary  expedi- 
ents are  enough  sometimes  to  keep  the  limb  at  rest  while  the  patient 
sits  or  even  walks  about ;  but  the  appliance  in  which  efficient  fixation 
can  be  most  easily  and  securely  attained  is  Thomas's  splint. 

Whether  a  case  be  treated  in  bed  or  going  about  must  depend  upon 
the  sensitiveness  and  the  circumstances  of  the  patient.  As  a  rule,  in 
synovitis  he  can  bear  his  weight  on  the  limb  when  fixed  straight,  and 
sometimes  in  capsular  arthritis  also.  For  this  reason  it  is  seldom  neces- 
sary to  have  Thomas's  splint  longer  than  the  limb  in  cases  of  this  kind. 
At  first  Thomas  took  the  weight  off  the  knee  in  all  cases,  but  afterward 
he  simply  fixed  the  joint  in  synovitis,  and  eventually  found  increased 
use  for  the  calliper  splint  in  mild  cases  of  capsular  arthritis,  many  cases 
recovering,  after  previous  use  of  the  longer  splint,  with  compensating 
patten  on  the  other  foot.  It  is,  moreover,  possible  to  take  the  weight 
of  the  body  from  the  affected  limb  in  walking  by  merely  making  the 
calliper  splint  of  full  length.  The  ischial  region  then  rests  on  the 
top  ring,  on  which  most  of  the  body's  weight  is  then  borne  at  each 
step. 

It  is  not  to  be  supposed  that  all  cases  of  synovitis  can  be  cured 
with  perfect  mechanical  treatment,  even  when  supplemented  by 
aspiration.  Cases  of  suppuration  may  require  incision.  Some  are  so 
virulent  that  total  destruction  of  the  joint  results,  and  amputation  is 
required  to  save  life.  Others  go  on  to  firm  ankylosis  of  the  joint,  in 
spite  of  all  attempts  at  antiseptic  management.  These  are  usually  cases 
of  peculiar  infection,  not  limited  to  suppuration,  but  attended  also  with 
necrosis  of  connective  tissue.  They  may  be  idiopathic  or  traumatic. 
In  the  former  event,  broken-down  constitutions  are  commonly  a 
favoring  condition  ;  in  the  latter,  wound  of  the  knee-joint,  imperfectly 
investigated  or  otherwise  subjected  to  mixed  infection.  When  once 
obstinate  suppuration  of  the  knee-joint  is  established,  ankylosis  is 
almost  certain  to  result  if  the  patient  and  the  limb  survive.  In  punct- 
ure or  other  wound  of  the  knee-joint,  and  more  especially  if  that  event 
be  merely  suspected,  the  only  wise  course  is  to  explore  the  wound 
under  an  anesthetic,  carefully  fix  the  limb  straight,  and  apply  an  anti- 
septic dressing  to  the  part,  preferably  without  closing  the  wound. 

Sometimes,  in  chronic  synovitis  without  suppuration,  free  incision  of 
the  joint  is  required.  Such  operation  is  not  to  be  lightly  undertaken, 
and  only  after  proper  arrangements  for  antiseptic  management,  and 
the  most  careful  adjustment  of  the  splint,  which  for  this  and  all  the 
other  purposes  of  exactitude  should  be  that  of  Thomas. 


74-  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

Cases  of  tubercular  arthritis  can  with  advantage  be  mechanically 
treated  in  Thomas's  splint  at  first,  and  in  the  early  stages  with  bed  treat- 
ment as  well.  Many  cases  do  tolerably  well  with  simple  fixation  in  a 
plaster-of-Paris  bandage,  but  this  is  not  an  advisable  treatment.  The 
usual  ambulatory  treatment  should  be  by  the  long  Thomas  splint, 
preferably  supplemented  by  a  light  plaster-of-Paris  bandage  which 
prevents  flexion.  Traction  may  be  applied  as  in  hip  cases,  by  means 
of  adhesive  plaster  strips,  which  in  this  case  should  not  extend  above 
the  knee.  Traction  does  not  seem,  however,  to  be  as  essential  in 
the  treatment  of  the  knee  as  it  is  in  hip-disease.  The  high  sole 
and  crutches  should  always  be  used  till  the  convalescent  stage  is 
reached.  Slight  cases,  especially  in  children,  yield  remarkably  well, 
and  often  get  quite  sound  ;  but  in  the  event  of  abscess  the  case  is  differ- 
ent. Even  then,  in  children,  sound  healing  may  occur  after  bursting  or 
incision.  The  healing  is  sometimes  spontaneous  without  any  attempt  at 
antiseptic  dressing ;  but  in  spite  of  this  the  dressing  should  be  used 
whenever  the  condition  is  known  to  exist.  In  adolescents  or  adults  it 
often  happens  that  abscess  forms  in  one  corner  or  other  of  the  joint, 
and  it  is  well  in  such  cases  to  ascertain  quickly  whether  or  not  the 
abscess  comes  from  the  joint,  and  to  perform  excision  early,  before 
secondary  suppuration  has  occurred.  It  is  useless  to  temporize  with 
tubercular  arthritis  in  adults  or  adolescents  when  suppuration  exists  or 
when  the  articular  surfaces  are  eroded.  Even  in  the  absence  of  suppura- 
tion, a  puffy,  pulpy  synovitis,  unless  distinctly  relieved  by  mechanical 
treatment  and  evidently  diminishing,  should  be  submitted  to  opera- 
tion by  excision  or  amputation.  In  children,  however,  mechanical  treat- 
ment may  well  be  long  persisted  in.  When  improvement  occurs,  the 
rule  is  that  the  splint  with  the  patten  and  the  high  sole  on  the  sound 
foot  be  worn  till  reflex  spasm  disappears,  then  supplanted  by  the 
calliper  splint  during  the  long  period  of  protection  which  is  necessary 
here  as  in  hip  cases. 

Not  infrequently,  even  with  fair  treatment,  some  flexion  of  the  knee 
results,  and  in  the  less  successful  cases  subluxation  of  the  tibia  back- 
ward may  occur.  For  this  reason  reduction  of  flexion-deformity  in  the 
knee,  especially  in  the  later  cases,  is  difficult,  and,  where  forcible  reduc- 
tion is  advisable,  special  apparatus  is  necessary  to  correct  the  subluxa- 
tion together  with  the  flexion.  Where  actual  ankylosis  has  occurred, 
with  marked  flexion,  either  osteotomy  near  the  joint  or  excision  must 
be  resorted  to. 

Excision  of  the  Knee=joint. — In  excision  the  operation  should 
always  be  planned,  if  possible,  before  the  surface  is  broken  by  previous 
operation.  Careful  aseptic  puncture  by  aspiration  need  not  vitiate 
the  condition  most  desired  in  excision,  nor  even  exploratory  incision, 
if  performed  within  twenty-four  hours  under  stringent  antiseptic  pre- 
cautions. Having  opened  the  joint  by  a  transverse  incision  passing 
between  the  patella  and  tibia,  the  ligaments  are  divided,  and  a  slice  sawn 
off  the  femur  and  tibia  in  the  horizontal  plane  of  the  joint,  so  as  to 
result  after  union  in  a  perfectly  straight  limb.  All  suppurative,  caseous, 
and  tubercular  tissues  are  carefully  removed,  even  to  the  extent,  when 
necessary,  of  complete  dissection  away  of  the  capsule  and  of  the  whole 
of  the  patella.     After  arresting  the  hemorrhage  and  applying  copious 


DISEASES   OF  THE  ANKLE-JOINT.  743 

irrigation  with  hot  water,  the  bones  are  placed  together,  the  integu- 
ments closed  by  a  few  sutures,  and  the  wound  enveloped  in  sterilized 
gauze.  The  writer  has  always  used  Thomas's  splint,  with  which  the 
desired  fixation  can  be  attained.  A  long,  wide,  hollow  splint  of  sheet 
iron,  moderately  padded  and  enclosed  in  mackintosh  water-proofing, 
is  laid  behind  the  limb,  from  the  top  of  the  thigh  to  the  middle 
of  the  calf,  slung  to  the  bars  of  the  Thomas's  splint.  The  foot  is 
enclosed  in  sterilized  gauze,  covered  with  plenty  of  cotton  wadding 
folded  round  it  in  long  strips,  and  bandaged  firmly  to  the  bars  of 
the  splint  in  an  easy  but  immovable  position.  The  skin  and  calf  are 
enveloped  in  similar  material,  soft  and  thick,  and  bandaged  perma- 
nently to  the  splint.  For  several  inches  above  and  below  the  wound 
are  placed  dressings  of  gauze,  which  can  be  slipped  away  and  freshly 
interposed  a  day  or  two  after  operation,  and  occasionally  afterward, 
without  disturbing  the  general  arrangement  of  the  splint  or  the  qui- 
escent attitude  of  the  limb.  Above  and  below  the  wound-dressings, 
between  the  posterior  waterproof  splint  and  the  limb,  is  placed  some 
wool  sheeting,  so  that  all  may  be  comfortable  and  free  from  damp, 
or  in  a  position  to  dry  readily  by  evaporation.  When  the  conditions 
are  favorable,  good  healing  of  soft  parts  and  firm  union  of  bone 
quickly  occur.  Sometimes  a  stitch-abscess  or  even  a  tubercular 
granulation  or  abscess  may  form,  without  detriment  or  serious  delay, 
and  can,  if  necessary,  be  dealt  with  by  a  minor  excision  or  scraping. 
But  the  rule  is  quick  recoveiy,  very  like  what  occurs  in  a  well-con- 
ducted aseptic  compound  fracture,  with  even  no  more  disturbance  than 
occurs  in  simple  fracture.  In  emaciated  adults  having  profuse  sup- 
puration or  septic  sinuses  connected  with  the  knee-joint,  it  is  com- 
monly safer  to  resort  to  amputation.  Even  here  amputation  should  not 
always  be  done,  and  the  writer  has  succeeded  with  excision  when  the 
risk  of  failure  or  even  death  was  encountered.  In  such  cases  months 
instead  of  weeks  may  be  required  for  the  necessary  healing,  and  the 
expected  risk  should  not  often  be  faced  except  at  the  urgent  request 
of  the  patient,  and  with  a  reasonable  expectation  of  success. 

The  object  of  excision  is  to  get  rid  of  the  tubercular  or  other 
inflammatory  process  ;  and  as  this  cannot  be  done  while  retaining  the 
surfaces  and  movements  of  the  joint,  some  bone  has  to  be  removed, 
even  if  not  actually  diseased,  in  order  to  bring  about  the  most  favor- 
able and  durable  ankylosis.  Even  when  the  bone-surfaces  are  involved, 
it  is  only  superficially,  as  a  rule,  and  no  more  than  a  thin  slice  has 
usually  to  be  removed.  Excision  is  also  required  sometimes  in  order 
to  straighten  a  limb  ankylosed  in  the  flexed  position,  although  oste- 
otomy is  usually  possible,  with  good  results. 

DISEASES  OF  THE  ANKLE-JOINT. 

Synovitis  may  occur  from  a  simple  sprain,  and  in  milder  cases,  if 
treated  immediately  by  strapping  and  bandage  as  employed  by  Pagan 
Lowe  of  Bath,  will  recover  more  or  less  quickly,  under  certain  condi- 
tions, without  confinement  to  bed.  In  severe  cases  more  complete  rest 
in  plaster,  usually  in  bed  as  well,  is  necessary  to  speedy  repair  A 
neglected   sprain   of  the   ankle   may  be  a  most  tedious  affair,  and  in 


744  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

delicate  persons  may  go  on  to  tubercular  arthritis,  suppuration,  and 
fatal  phthisis,  or  in  other  cases  to  destruction  of  the  joint  and  the 
necessity  of  amputation. 

Certain  cases  of  acute  or  subacute  arthritis  of  the  ankle  are  of 
gonorrheal  origin,  and  are  remedied  by  early  fixation  in  a  suitable 
splint. 

Tuberculosis  of  the  ankle  is  usually  primary,  and,  save  in  the  case 
of  the  os  calcis,  the  process  rapidly  involves  the  whole  tarsus.  Early 
tubercular  arthritis  of  the  ankle,  without  suppuration,  may  be  fittingly 
treated  by  Thomas's  skeleton  splint  of  iron  rod  reaching  up  to  the  calf, 
or  by  a  plaster-of-Paris  bandage.  The  addition  of  Thomas's  knee-splint, 
for  progression,  is  an  invaluable  help.  The  writer  has  no  experience  of 
excision  of  the  ankle-joint,  having  treated  advanced  cases  by  amputation, 
either  above  or  at  the  articulation.  The  operation  of  excision  should, 
however,  be  considered,  and,  especially  in  children,  has  given  good  func- 
tional results.  The  time  required  for  after-treatment  is  long,  and  in  chil- 
dren it  is  more  often  justifiable  to  undertake  a  long  course  of  treatment 
than  in  adults.  Enough  good  results  from  excision  in  children  have  been 
reported  to  make  the  operation  distinctly  worth  while  in  suitable  cases. 
In  adults  amputation  should  be  the  usual  resort  in  advanced  tubercular 
disease  of  the  ankle-joint.  In  differential  diagnosis  arthritis  deformans, 
flat-foot,  and  the  other  static  disorders  are  especially  to  be  considered. 

DISEASES  OF  THE  SHOULDER-JOINT. 

Disease  of  the  shoulder-joint  seldom  takes  the  form  of  synovitis. 
Whether  it  be  that  the  joint  is  not  ordinarily  capable  of  much  disten- 
tion (it  has  been  supposed  that  the  capsule  easily  gives  way  where  the 
biceps  tendon  traverses  it,  and  lets  fluid  escape  into  the  surrounding 
tissues),  or  whatever  be  the  explanation,  inflammation  of  the  shoulder 
is  hardly  ever  attended  by  fluid  distention. 

Sprain  of  the  Shoulder. — Puffy  edema  in  sprain  or  arthritis  of 
the  shoulder  may  easily  occur,  and  is  not  to  be  mistaken  for  synovial 
effusion.  In  the  examination  of  an  injured  shoulder  or  upper  arm  it 
is  often  advantageous  to  examine  in  narcosis  ;  if  this  is  not  done,  it 
is  of  great  practical  assistance  to  the  surgeon  and  a  comfort  to  the 
patient,  after  stripping,  to  flex  the  elbow  and  sling  the  wrist  to  the 
neck,  for  which  purpose  a  folded  handkerchief  or  other  triangular 
bandage  is  the  most  handy.  The  weight  of  the  forearm  is  thus 
transferred  to  the  neck,  and  taken  off  the  upper  arm  and  shoulder, 
which  latter  parts  are  then  most  easily  and  painlessly  examined. 
With  one  hand  on  the  shoulder  and  the  other  holding  the  elbow, 
gentle  movement  can  be  made  to  distinguish  between  fracture  of 
the  clavicle  or  upper  end  of  the  humerus  and  sprained  shoulder. 
In  the  latter  affection  creaking  of  the  capsule  may  give  a  sensa- 
tion something  like  crepitus.  In  the  treatment  of  sprained  shoulder 
the  position  just  described  for  the  examination  is  continued  till  the 
part  is  well,  the  wrist  being  slung  to  the  neck  at  a  convenient  height 
and  the  arm  strictly  confined  to  the  body  by  a  wide  bandage  around 
both  arm  and  body,  immediately  above  the  elbow.  This  prevents 
movement  in  the  shoulder-joint,  which  must  further  be  protected  from 


DISEASES   OF   THE   ELBOW-JOINT.  745 

pressure  by  keeping  the  patient  from  lying  on  it  when  in  bed.  A  few 
strips  of  plaster  may  be  laid  on  the  shoulder,  in  the  event  of  great  ten- 
derness, both  horizontally  and  vertically.  This  will  fix  the  skin  and 
help  to  secure  comfort  and  rest.  There  is  no  need  of  any  splint  or 
casing  of  leather,  gutta-percha,  or  mill-board,  as  all  the  necessary  pro- 
tection can  be  quickly  applied  in  the  form  of  many  strips  of  plaster. 
If  these  be  made  of  brown  paper  rendered  adhesive  by  a  solution  of 
pitch  in  benzolin,  the  skin  is  kept  aseptic  and  free  from  much  itching. 
To  cool  the  shoulder,  moreover,  the  paper  plaster  may  be  moistened 
after  application,  with  grateful  effect.  In  chronic  inflammation  of  the 
shoulder-joint  there  is  more  or  less  tenderness,  but  especially  stiffness, 
recognizable  from  behind  on  passive  abduction  of  the  elbow  while  the 
wrist  is  slung  to  the  neck.  In  proportion  to  the  stiffness,  the  scapula 
moves  with  the  upper  limb  in  abduction ;  but  during  the  progress 
to  recovery  the  amount  of  this  stiffness  gradually  diminishes.  In 
neglected  or  obstinate  cases  the  flexed  and  slung  limb  has  to  be  tied 
up  against  the  trunk  for  months,  but  may  often  be  got  well  with  per- 
severance. 

Arthritis  of  the  shoulder  in  cases  of  tubercle  or  osteomyelitis  is 
frequently  attended  with  abscess,  which  may  burst  and  leave  sinuses, 
commonly  opening  before  or  behind  the  surgical  neck  of  the  humerus. 
Operation  in  these  cases  should  be  strictly  limited  to  the  necessities  of 
the  case.  After  incision,  necrosed  or  carious  bone  can  be  dealt  with 
in  osteomyelitis  by  removal  of  sequestra  or  gouging  of  surface,  with- 
out interfering  with  the  articulation  in  every  case.  Such  cases  may  at 
first  be  easily  mistaken  for  tubercle,  and  they  sometimes  cause  surprise 
at  their  quick  and  easy  recovery.  But  whether  in  osteomyelitis  or 
tubercle,  if  septic  sinuses  communicate  with  the  joint,  and  the  artic- 
ular surfaces  of  the  bones  be  eroded,  it  is  best  to  turn  out  the 
head  of  the  humerus  and  remove  it  by  excision.  A  vertical  incision 
on  the  front  of  the  joint  is  the  best ;  but  the  position  of  sinuses  may 
dictate  a  different  direction  in  which  to  open  the  joint,  such  as  the 
older-fashioned  deltoid  flap  raised  up  from  below,  or  some  other  that 
the  exigencies  of  the  case  may  suggest.  During  the  healing  of  the 
wound  the  limb  should  be  slung  as  above  described.  This  device,  in 
cases  not  requiring  operation,  was  practised  by  the  late  H.  O.  Thomas. 

In  acute  rheumatism,  transitory  inflammation  and  pain  in  the 
shoulder-joint  occur,  but  the  recumbent  position,  without  appliance, 
is  commonly  sufficient  for  the  needs  of  this  particular  joint. 

DISEASES  OF  THE  ELBOW-JOINT. 

Sprain. — The  elbow-joint  is  frequently  sprained  by  falling  and 
otherwise.  The  result  is  pain,  heat,  swelling,  and  disablement,  the 
characteristic  symptoms  of  inflammation.  Synovial  effusion  may 
sometimes  occur,  and  the  writer  has  seen  it  in  chronic  inflamma- 
tion. The  moment  an  elbow  becomes  acutely  inflamed,  the  pain  ham- 
pers the  movement  and  seriously  incommodes  the  patient.  If  laid 
in  bed  on  a  pillow,  the  painful  limb  is  disturbed  at  each  change  of 
position.  If  conventional  routine  treatment  be  adopted  and  fomenta- 
tions applied,  without  the  simple  precaution  of  fixing  the  limb  in  an 


74-6  INTERNATIONAL    TEXT- BO  OK  OE  SURGERY. 

immovable  easy  position,  days  may  be  spent  in  "  taking  down  the 
swelling,"  as  this  process  is  called.  The  best  plan  is  to  strip  the  patient 
to  the  waist  and  sling  the  arm  to  the  side,  with  the  wrist  firmly  and 
comfortably  attached  to  the  neck  by  a  soft  folded  handkerchief  or  other 
form  of  triangular  bandage.  If  attended  to  immediately  after  injury,  a 
rectangular  position  or  flexion  to  a  smaller  angle  may  be  found  a  speedy 
relief;  and  if  there  is  no  fracture,  all  that  is  required  is  to  continue  this  atti- 
tude without  change,  applying  the  clothing  as  may  be  most  convenient 
over  the  limb  thus  fixed  to  the  body.  If,  in  addition,  fomentations  be  ap- 
plied, well  and  good  ;  but  if  the  limb  has  been  hanging  straight  or  at  an 
obtuse  angle  for  many  hours,  the  attainment  of  the  flexed  position  will 
be  painful  at  first.  It  can  usually,  however,  be  sufficiently  bent,  by 
gradual  and  gentle  manipulation  for  a  few  minutes,  to  attach  the  wrist 
to  the  neck  and  keep  the  limb  against  the  trunk.  This  secures  a  posi- 
tion of  rest  which  can  be  maintained  at  a  right  angle  or  lesser  angle 
pending  recovery.  No  splint  is  required,  nor  would  a  splint  be  capable 
of  attaining  anything  like  the  accuracy  and  comfort  of  the  mere  sling. 

In  the  progress  to  recovery  the  arm  at  first  continues  disabled,  and 
when  freed  from  the  sling  tends  to  drop  helplessly  unless  supported 
by  the  other  limb  or  by  another  person.  By  degrees,  however,  the 
elbow  can  be  held  unsupported  at  the  angle  at  which  it  has  been  slung, 
and  eventually  it  can  be  flexed  to  less  than  a  right  angle.  This  is  a 
test  of  approaching  fitness  for  use. 

Arthritis. — An  ordinary  sprain  may  develop  into  a  subacute  or 
chronic  arthritis,  especially  in  tubercular  persons,  if  left  to  itself,  or  to  the 
comparatively  perfunctory  assistance  of  fomentations,  without  mechanical 
help.  Such  arthritis  may  recover  completely  after  due  employment  of 
rest  in  the  slung  flexed  position  ;  but  in  tubercle  a  pulpy  condition  of 
the  capsule  may  result,  with  or  without  masses  of  granulations  or  ab- 
scess. A  condition  of  "white  swelling"  of  the  elbow,  with  emaciation 
of  the  limb  above  and  below,  is  typical  of  the  advanced  tuber- 
cular change,  and,  save  in  young  children,  there  is  no  advantageous 
treatment  for  this,  short  of  excision.  A  linear  incision  behind  the 
joint,  with  dissection  of  the  soft  parts  of  the  bones  right  and  left,  care 
being  taken  to  keep  close  to  the  inner  condyle,  and  to  lift  off  the 
ulnar  nerve  intact  with  the  other  soft  parts  after  separation  of  the  liga- 
ments, leads  to  exposure  of  the  articular  ends  of  the  bones,  which  can 
now  be  sawn  off  beyond  the  cartilages.  All  tubercular  soft  parts 
should  be  carefully  dissected  away,  or  scraped  with  a  sharp  spoon, 
whichever  more  effectually  answers  the  purpose  at  each  locality.  The 
term  "  arthrectomy  "  is  sometimes  applied  to  this  part  of  the  process  ; 
but  the  object  desired  is  not  necessarily  removal  of  all  the  articular 
structures  so  much  as  the  removal  of  all  tissues  visibly  affected  by  the 
tubercular  process.  Caseous  and  granulation  masses  can  be  easily 
scraped  away  with  the  sharp  spoon,  but  capsular  and  other  fibrous  tis- 
sues containing  miliary  tubercles  require  dissection.  After  arresting 
the  hemorrhage  and  irrigating  well  with  hot  water,  a  few  sutures  are 
put  in,  and  the  limb  placed  in  a  proper  position  to  receive  the  dressings. 
The  writer  always  ties  the  wrist  to  the  neck  with  a  triangular  bandage, 
the  elbow,  however,  being  flexed  at  a  right  angle,  or  even  a  smaller 
angle,  in  which  position  the   part  is  enveloped   in   carbolized  cyanide 


DISEASES   OE   THE   ELBOW-JOINT.  747 

gauze  bandaged  on.  The  effect  of  this  position  is  to  keep  the  limb  in 
contact  with  the  trunk.  Wherever  the  body  goes,  the  limb  goes  with 
it,  and  the  comfort  of  the  patient  is  promoted  ;  or  in  other  words,  any 
discomfort  attending  the  operation  is  reduced  to  a  minimum.  The 
writer  is  opposed  to  the  use  of  a  splint,  or  to  laying  the  limb  on  a 
pillow  "  at  an  obtuse  angle  "  after  excision  of  the  elbow.  By  slinging 
the  wrist  to  the  neck  and  the  arm  to  the  side,  the  pain  and  tenderness 
resulting  from  the  wound  are  quickly  got  rid  of,  and  the  patient 
enabled  to  get  up  in  a  much  shorter  time  than  would  otherwise  be  the 
case.  The  number  of  days  or  hours  of  confinement  to  bed  varies 
with  each  case,  but  the  writer  has  had  patients  able  to  be  up  and 
about  the  day  after  excision,  though  commonly  a  day  or  two  more 
elapses  before  this  event.  There  seems  to  be  no  need  to  submit  the 
patient  to  "passive  movement"  of  the  excised  elbow.  It  is  sufficient 
at  first  to  keep  the  wound  at  rest  for  healing  purposes.  But  the  posi- 
tion of  the  limb  may  be  slightly  changed  after  a  week  or  two,  alterna- 
ting between  a  right  angle  and  a  more  acute  angle.  In  the  opinion  of 
the  writer,  it  is  quite  time  enough  to  accustom  the  elbow  to  slight 
changes  of  position  when  the  healing  is  either  completed  or  well 
advanced.  Primary  union  may  occur  throughout  if  the  circumstances 
are  favorable,  or,  as  a  rule,  in  the  greater  part  of  the  wound  at  least ; 
but  if  not,  each  event  will  be  dealt  with  as  its  circumstances  require. 
After  healing,  fresh  tubercle  may  develop  here  or  there,  and  must  be 
cut  out  if  manifested.  No  case  should  be  dismissed  or  lost  sight  of 
until  completely  healed ;  and  any  delay  in  the  healing  should  be 
promptly  treated  by  exploration,  excision,  scraping,  or  other  antiseptic 
management. 

Excision  may  be  required  for  septic  arthritis  with  sinuses  following 
injury,  for  ankylosis,  or  for  bad  union  or  non-union  of  fractures  at  or 
near  the  elbow-joint.  In  some  cases,  especially  where  the  surface  is 
unbroken,  opportunity  arises  for  modifying  the  details  of  operation  in 
the  interest  of  the  patient  and  to  the  mechanical  advantage  of  the  limb. 
Such  a  case  occurred  to  the  writer  in  July,  1897,  in  which  a  stiff  ex- 
tended elbow  following  a  fracture  of  the  outer  condyle  of  the  humerus 
into  the  joint  was  submitted  to  excision.  The  broken  and  ununited 
outer  condyle  was  cut  away  with  the  knife,  a  thin  slice  only  being 
removed  from  the  head  of  the  radius,  so  as  to  retain  the  orbicular  liga- 
ment;  the  ulna,  after  removal  of  the  olecranon,  articulated  opportunely 
with  the  broken  outer  side  of  the  inner  condyle,  where  it  found  good 
support ;  a  strong  and  greatly  thickened  anterior  ligament  of  the  joint 
formed  a  bond  of  union  which  was  gladly  left  alone,  and  the  result  was 
admirable  mobility  and  strength  of  elbow  after  a  very  quick  healing. 
The  patient,  a  member  of  the  civil  service  who  had  come  home  from 
India  for  treatment,  went  away  again  well  able  to  ride  and  drive,  to 
convey  food  to  his  mouth,  and,  in  fact,  to  perform  all  necessary  acts 
with  a  limb  previously  quite  useless  to  him.  He  visited  the  writer  early 
in  January,  1901.  and  on  the  25th  confirmed  the  result  before  the 
Clinical  Society  of  London. 

The  object  of  surgery  is  to  procure,  if  possible,  a  moveable  elbow; 
but  too  much  should  not  be  sacrificed  to  this  end.  Ankylosis  at  a 
right  angle,  firm  and  strong,  though  usually  a  less  desirable  result  than 


748  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

flexibility,  is  not  necessarily  to  be  despised,  especially  if  the  latter  result 
be  attended  with  very  feeble  power  or,  what  is  worse,  an  uncontrollable 
"  flail."  The  writer  had  once  for  a  patient  a  joiner  in  whom  the  right 
elbow  was  firmly  ankylosed  at  a  right  angle.  The  man  could  use  a  saw 
to  his  own  satisfaction,  and  was  quite  content  with  the  result — in  fact, 
did  not  desire  operation  to  procure  mobility,  which  might  easily  have 
been  attended  with  an  enfeebled  limb. 

In  acute  rheumatism  the  elbows,  when  affected  consecutively,  as 
usually  happens,  are  sufficiently  protected  in  the  ordinary  attitude,  as 
the  arms  lie  on  the  bed  and  the  forearms  on  the  trunk.  No  inter- 
ference is  commonly  required,  and  the  inflammation  generally  dis- 
appears in  a  few  days. 

It  will  be  noticed  from  what  has  been  said  that  the  mechanical 
treatment  of  the  shoulder  and  elbow  differs  from  that  adopted  in  other 
joints.  In  the  hip  and  knee,  fixation  and  mechanical  rest  are  obtained 
by  splint,  in  a  straight  line.  The  same  will  be  found  to  apply  to  the 
wrist.  In  the  elbow,  the  limb  is  folded  against  the  trunk  and  slung 
there  in  the  flexed  position  of  the  joint.  In  the  shoulder,  the  same 
attitude  is  used,  and,  in  addition,  the  elbow  is  confined  to  the  side,  to 
prevent  movement  in  the  shoulder-joint. 

DISEASES  OF  THE  WRIST. 

The  wrist-joint  is  liable  to  inflammation  owing  to  sprains,  some  of 
which  are  attended  by  swelling  of  the  tendon-sheaths  around  the 
radius,  more  or  less  resembling  cases  of  Colles'  fracture,  such  as  some- 
times occur  with  very  slight  deformity. 

Acute  Rheumatism. — Inflammation  of  the  wrist-joint  is  a  com- 
mon feature  in  acute  rheumatism,  and  a  source  of  great  annoyance  to 
the  patient  while  it  lasts.  The  usually  transitory  character  of  acute 
rheumatic  arthritis,  and  the  fact  that  the  other  joints  are  pretty  well  at 
rest  as  the  patient  lies  in  bed,  have  caused  the  affection  of  the  wrists, 
during  the  few  days  that  it  lasts,  to  be  not  quite  sufficiently  noticed. 
The  late  Professor  John  Marshall  drew  the  attention  of  the  writer  to 
the  great  comfort  afforded  to  a  member  of  his  own  family  during  rheu- 
matic fever  by  promptly  supporting  the  wrists  in  suitable  splints  as 
they  became  in  turn  affected — a  practice  that  the  writer  has  since 
repeatedly  followed.  The  wrists  are  practically  the  only  joints  that 
require  surgical  treatment  in  acute  rheumatism,  and  the  contrast 
between  the  comfort  thus  attained  and  the  painful  helplessness  of  those 
left  alone  or  submitted  to  loose  applications  of  cotton-wool  or  the 
equally  useless  "  fomentations  "  is  too  evident,  when  witnessed,  to  need 
more  than  mere  mention. 

Gonorrheal  rheumatism  of  the  wrist,  like  gonorrheal  rheuma- 
tism of  other  joints,  would  appear  to  vary  according  to  individual 
patients  and  experiences.  In  the  experience  of  the  writer,  this  affection, 
wherever  found,  has  been  usually  mild  and  eminently  amenable  to 
mechanical  treatment,  except  in  a  single  case  of  unusual  severity  affect- 
ing the  knees  and  ankles. 

Tubercular  inflammation  of  the  wrist  is  an  affection  of  very 
varying  extent  and  severity.     It  often  begins  insidiously  and  quietly, 


DISEASES   OF  THE    WRIST.  749 

producing  so  little  inconvenience  that  serious  destruction  may  occur 
before  treatment,  which  might  earlier  have  been  curative,  is  ever  asked 
for.  There  is  every  degree  between  a  slight  arthritis  and  puffy  excres- 
cences of  granulation  and  caseous  tissue  pouching  out  the  joint  at 
various  points.  When  abscess  forms  and  bursts  spontaneously,  a 
sinus  is  left.  In  middle  life  such  a  complication  requires  amputation 
of  the  forearm  (Fig.  366).     Abscess  of  the  wrist-joint  treated  with  an 


Fig.  366. — Senile  tubercle  of  the  wrist  treated  by  amputation.     Puffy  swelling  and  sinuses. 

unbroken  surface  may  be  opened  antiseptically,  and  may  heal  without 
any  further  suppuration  at  any  age.  In  childhood  and  youth  much 
may  be  done  in  the  conservative  management  of  tubercular  inflamma- 
tion of  the  wrist  with  splints  and  antiseptic  incisions,  with  or  without 
removal  of  bone  where  diseased. 

The  mechanical  treatment  of  the  wrist  should  be  promptly 
and  thoroughly  attended  to  in  all  cases  requiring  it.  Well-fitting 
splints  of  wood  or  sheet  metal,  hollowed  for  better  adaptation  to  the 
limb,  and  suitably  padded,  reaching  from  the  tips  of  the  fingers  to  a 
point  above  the  middle  of  the  forearm,  can  be  used  for  this  purpose 
both  effectually  and  neatly  when  not  bulky.  But  a  most  convenient 
splint  can  be  improvised  out  of  folded  newspaper  in  many  layers,  in 
the  form  of  a  trough  wide  enough  to  encircle  the  limb,  enclosing  the 
hand,  wrist,  and  forearm,  excluding  the  thumb,  and  bandaged  firmly 
to  the  limb  without  any  kind  of  padding.  For  severely  sprained 
wrist  the  early  application  of  such  a  splint  is  promptly  attended  by 
relief  of  all  symptoms.  Of  course,  to  be  efficient,  the  paper  splint 
must  be  firm  enough  to  rigidly  prevent  all  movement  of  the  wrist. 
The  apparatus  is  left  on  till  recovery  is  complete,  and  a  single  appli- 
cation may  suffice  in  many  instances.  Perspiration  escapes  through 
the  paper,  which  also  lies  smoothly  and  comfortably  in  contact  with 
the  skin.  In  the  event  of  excoriation,  or,  in  fact,  at  any  time,  the  limb 
may  be  covered  with  a  few  layers  of  antiseptic  gauze,  which  will  suffice 
to  preserve  the  surface  of  the  skin  and  to  render  unnecessary  the  sub- 
sequent inspection  of  trifling  breaches  of  surface.  The  same  kind  of 
splint  will  do  for  arthritis  of  the  wrist  unattended  with  sinus,  abscess, 
or  wound.  In  the  event  of  abscess,  the  limb  may  be  attached  to  a 
single  splint  of  wood  or  sheet  metal,  after  opening,  scraping,  washing, 


750  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

and  dressing  with  cyanide  gauze.  The  dressings  may  be  so  arranged 
as  to  be  changed  without  disturbing  the  splint.  After  healing,  a  good 
splint  can  be  readily  constructed  by  bandaging  on  a  piece  of  sole- 
leather  softened  in  water,  in  the  form  of  a  long  gauntlet  closely  fitting 
the  limb,  its  open  side  lying  along  its  radial  edge,  leaving  out  the 
thumb.  When  the  gauntlet  is  dry,  it  can  be  removed,  trimmed  with 
a  knife,  perforated  with  a  few  holes,  and  re-applied  with  a  lace  to  hold 
it  close.  In  certain  tubercular  cases  perfect  healing  of  the  abscess 
may  be  thus  attained  by  attention  to  antiseptic  principles ;  but  there 
may  sometimes  result  inevitable  stiffness,  due  to  ankylosis  in  the 
wrist  or  radio-ulnar  joint.  Such  cases  present  great  varieties  of  con- 
dition and  incident,  but  often  will  repay  careful  efforts  to  save  them. 
There  is  no  use  temporizing,  however,  in  cases  of  sinus  in  middle 
life.  Prompt  amputation  is  the  most  judicious  treatment,  as  experi- 
ence has  amply  shown.  In  children  and  young  adults  operations 
of  a  "cheese-paring"  description  may  profitably  be  undertaken,  inflam- 
matory exudation,  diseased  bone,  and  other  products  of  tubercular 
disease  being  excised  by  such  means  as  the  necessities  of  the  case  and 
the  ingenuity  of  the  surgeon  suggest.  Formal  excision  of  the  whole 
joint  is  seldom  called  for,  even  by  the  excellent  method  devised  long 
ago  by  Professor  Lister.  The  writer  has  succeeded  admirably  in  a  few 
cases  by  adopting  the  "partial"  method  of  extirpating  the  local  disease, 
subsequently  preferred  by  Lister  himself  to  his  earlier  practice. 


CHAPTER   XXII. 

CONGENITAL   DISLOCATION  OF   THE  HIP;  FLAT-FOOT; 

CLUB-FOOT. 

CONGENITAL  DISLOCATION  OF  THE  HIP. 

Congenital  dislocation  of  the  hip  is  a  dislocation  of  the  head  of 
the  femur  occurring  in   uterine  life. 

Etiology. — The  etiology  is  not  known,  but  it  is  certain  that  the 
dislocation  occurs  in  uterine  life.  Girls  are  much  more  commonly 
subject  to  this  affection  than  boys.  An  explanation  has  been  offered,  with 
some  plausibility,  that  under  certain  conditions  an  exaggerated  lordosis 
is  developed  in  fetal  life,  owing  to  an  anomaly  of  the  position  of  the  fetal 
liver.  This  predisposes  toward  a  dislocation  of  the  head  of  the  femur 
from  uterine  pressure.  As  sexual  difference  in  the  shape  of  the  pelvis 
is  seen  as  early  as  the  fourth  or  fifth  month  in  fetal  life,  girls  would  be 
more  predisposed  than  boys. 

Pathological  Anatomy. — Changes  in  the  Capsule. — These  are  the  most  impor- 
tant pathological  changes,  and  they  are  of  gradual  development.  There  is  no  rupture  of  the 
capsule,  as  in  a  traumatic  dislocation,  but  it  is  altered  by  being  stretched  by  the  head  of  the 
bone,  is  forced  upward,  and  is  thickened  and  strengthened  as  the  weight  of  the  child 
increases.  The  shape  of  the  capsule  becomes  altered  from  that  of  an  irregular  globe  con- 
necting the  acetabulum  and  femur,  and  can  be  likened  to  a  purse-bag  glued  to  the  bone,  the 
lower  portion  covering  the  acetabulum,  the  free  portion  enclosing  the  femoral  head,  and  the 
purse  neck  being  the  constricted  part  where  the  head  of  the  femur  left  the  acetabulum,  stretch- 
ing the  adherent  capsule  with  it.  What  may  be  termed  the  neck  of  the  capsule  becomes 
attached  on  its  iliac  surface  to  the  ilium,  and  this  attachment  maybe  unusually  firm  ;  that  cov- 
ering the  acetabulum  becomes  altered,  and  with  the  changes  of  the  synovial  membrane  and 
stretched  cotyloid  ligament  resembles  firm  fibrous  tissue,  filling  as  well  as  covering  the  socket, 
so  that  the  cavity  may  be  obliterated.      Portions  of  the  capsule  may  be  much  thickened. 

Alterations  in  the  Muscles. — The  changes  in  the  length  and  direction  of  muscles 
between  the  pelvis  and  femur  vary  according  to  the  altered  position  of  these  bones.  These 
alterations  offer  less  resistance  to  reduction  than  those  of  the  capsule,  but  they  may  be  an 
important  factor  in  causing  a  relapse  and  in  resisting  complete  correction.  The  pelvifemoral 
muscles  are  especially  to  be  considered — viz.,  the  adductors,  the  tensor  vaginae  femoris  and 
the  fascia  lata,  the  reflected  head  of  the  rectus,  and  also  the  hamstring  muscles,  together 
with  the  psoas  and  iliacus.  Those  inserted  at  the  great  trochanter  are  not  shortened,  and 
may  be  lengthened. 

Alterations  in  the  Bones. — The  acetabulum  becomes  shallow  and  triangular,  and 
its  hyaline  cartilage  is  replaced  bv  fibrous  tissue,  except  at  the  rim.  The  formation  of  a 
new  false  joint  with  osseous  socket  is  not  seen  in  congenital  dislocation  in  children,  and  is 
extremely  rare  in  adults.  Frequently  the  neck  of  the  femur  is  twisted  and  its  angle  with 
the  shaft  diminished.      The  head  may  be  small  and  pointed. 

The  varieties  of  dislocation  are  back-ward,  upward,  and  forward,  and  are  indicated  in 
general  by  the  position  of  the  leg  and  the  direction  of  the  foot. 

Diagnosis. — The  diagnosis  of  this  affection  is  not  difficult  in  adult 
cases  or  in  large  children,  as  the  characteristic  peculiarities  in  gait  and 
attitude  are  easily  seen.  In  smaller  children  these  affections  must  be 
eliminated:  coxa  vara,  distortion  following  infantile  paralysis,  separation 
of  the  epiphysis,  deformity  follozcing  early  arthritis  of  infancy,  traumatic 
dislocations,  and  the  deformities  of  hip-disease. 


752  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

In  all  these  affections  except  coxa  vara  there  should  be  a  history 
of  previous  injury  or  illness,  and  in  all  except  coxa  vara  and  infantile 
paralysis  the  freedom  of  motion  of  the  femur  seen  in  early  congenital 
dislocation  is  not  found.  In  coxa  vara  (rachitic  distortions  of  neck  of 
femur),  unlike  the  conditions  found  in  congenital  dislocation,  the  femur 
rotates  with  the  head  in  its  normal  socket  and  cannot  be  palpated. 
Coxa  vara  is  rare  before  five  years  of  age. 

Congenital  dislocation  is  characterized  by  marked  lordosis,  so  as  to 
be  frequently  mistaken  for  a  spinal  lesion.  Whether  the  dislocation 
be  unilateral  or  double,  the  gait  is  characteristic.  In  the  former 
instance  it  resembles  the  gait  on  the  free  side  of  an  organ-grinder 
carrying  a  barrel-organ ;  in  the  latter  instance  it  is  marked  by  a 
peculiar  side-to-side  movement.  The  gait  is  due  to  the  muscular  effort 
to  relieve  the  ligaments  of  tension  resulting  from  lack  of  bony  support. 
Fluoroscopic  examination,  when  feasible,  is  conclusive  evidence  in 
diagnosis. 

Prognosis. — The  disability  caused  by  this  affection  in  childhood 
is  slight.  The  limp  is  noticeable,  and  in  double  congenital  dislocation 
may  be  distressing.  As  the  patient  becomes  older  and  the  weight 
increases,  some  annoyance  may  be  caused  in  adolescence,  but  the 
disability  is  ordinarily  not  great  until  middle  life  or  old  age.  A  single 
dislocation  is  less  annoying.  An  increase  of  weight  or  overexertion 
may  cause  muscular  pain  and  spasms,  necessitating  the  temporary  use 
of  crutches,  particularly  in  feeble  subjects,  and  seriously  limiting 
activity. 

Treatment. — The  problem  to  be  solved  in  the  treatment  of  con- 
genital dislocations  of  the  hip  consists  in  replacing  the  head  of  the 
femur  into  the  acetabulum,  and  keeping  it  there,  so  that  the  weight  of 
the  trunk  is  transmitted  directly  to  the  femur.  The  most  important 
obstacle  to  reduction  lies  in  the  attachment  of  the  capsule,  displaced 
and  thickened,  to  the  ilium  above  and  around  the  front  of  the  acetab- 
ulum, and  to  the  anterior  surface  of  the  femur,  especially  to  the  lesser 
trochanter.  Of  more  or  less  importance  are  the  shortened  pelvifemoral 
muscles,  as  well  as  the  shape  of  the  head  and  the  shallowness  of  the 
acetabulum. 

The  methods  may  be  grouped  as  : 

1.  Reduction  after  incision. 

2.  Reduction  by  forceful  manipulation. 

3.  Gradual  reduction  by  mechanical  appliances. 

Reduction  after  Incision. — The  first  successful  operative  method 
was  devised  by  Hoffa,  the  details  of  which  have  been  much  improved 
by  Lorenz  and  by  himself.  The  patient  is  to  be  placed  upon  the  back 
with  the  limb  abducted  and  rotated  outward.  The  incision  is  made  in 
a  line  drawn  from  in  front  of  the  anterior  superior  spine,  obliquely 
downward  and  forward,  crossing  the  femur  a  short  distance  below  the 
top  of  the  trochanter  (Fig.  367).  The  incision  should  be  along  the 
outer  edge  of  the  tensor  vaginae  femoris,  between  this  and  the  anterior 
border  of  the  gluteus  medius.  The  incision  should  pass  below  the  tro- 
chanter, and  should  cross  the  femur  slightly  above  the  level  of  the  tro- 
chanter minor.  The  tensor  vaginae  femoris  is  retracted,  and  the  fascia  lata 
divided  by  a  straight  incision,  and,  if  necessary,  by  an  additional  cross 


CONGENITAL    DISLOCATION  OF   THE   HIP. 


753 


incision.  The  gluteus  is  also  retracted,  and  beneath  the  tensor  muscle 
the  rectus  femoris  will  be  found,  with  the  reflected  tendon  passing  out- 
ward, to  be  inserted  upon  the  ilium  above  the  acetabulum.  If  the  mus- 
cular tissues  are  well  retracted,  the  capsular  ligament  will  be  uncovered 
and  can  be  split.     This  should  be  done  by  an  incision  in  the  direction 


Fig.  367. — Line  of  skin-incision  for  operative 
reduction. 


Fig.  368. 


-Operative  reduction,  second 
step. 


of  the  original  skin-incision,  free  enough  to  expose  the  whole  head  and 
neck  as  far  as  the  trochanteric  line.  An  assistant  should  then  flex  the 
thigh  to  a  right  angle  with  the  trunk,  and  the  attachments  of  the  cap- 


Fig.  369. — Operative  reduction,  third  step.  Fig.  370. — Operative  reduction,  fourth  step. 


sule  to  the  neck  and  trochanteric  line,  including  the  lesser  trochanter, 
should  be  freed,  both  on  the  anterior  and  the  posterior  surface  of  the 
neck,  to  such  an  extent  that  the  surgeon  can  pass  his  finger  completely 
around  the  neck.  The  head  can  then  be  thrown  out  and  the  liga- 
mentum  teres  divided,  if  present.  The  head  of  the  femur  can  then  be 
pulled  aside,  and  a  clear  view  of  the  capsule  covering  a  portion  of  the 
acetabulum,  as  well  as  the  acetabulum  itself,  can  be  had.  A  curet  can 
then  be  introduced  to  deepen  the  acetabulum,  if  necessary.1  It  is 
important  that  the  bony  edge  overhanging  the  acetabulum  should  pro- 
ject sufficient]}'  to  furnish  a  firm  socket  after  the  head  is  reduced.  It 
is  sometimes  difficult,  if  the  tissues  are  imperfectly  divided,  to  find  the 

1  For  this  purpose  there  has  been  devised  by  Doyen  a  most  excellent  instrument  which 
bores  out  the  fibrous  tissue  from  the  acetabulum. 

4S 


754  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

socket,  for  the  reason  that  a  portion  of  the  capsule  lies  fiat  across  the 
socket  and  is  adherent  to  the  edges,  the  surgeon  feeling  only  the  upper 
cf\<g^  and  a  mass  of  connective  tissue.  This  connective  tissue  must  be 
divided  in  order  to  open  the  cavity. 

It  is  important  that  all  tense  bands  of  the  capsule  should  be  divided, 
and  that  no  portion  of  its  capsule  should  get  between  the  head  of  the 
femur  and  the  acetabulum.  The  femur  may  be  used  as  a  lever  to 
stretch  certain  undivided  portions  of  the  capsule. 

After  reduction,  the.  redundant  capsule  can  be  stitched  and  the 
wound  closed  or  drained  according  to  the  judgment  of  the  surgeon. 
Results  show  that  drainage  is  of  especial  importance  on  account  of  the 
depth  of  the  cavity  and  the  danger  of  infection  from  urine  in  small 
children. 

Where  there  is  a  marked  twist  in  the  neck,  it  is  necessary,  in  order 
to  keep  the  head  in  place,  to  invert  the  foot  strongly.  Before  the  pa- 
tient walks  upon  the  foot,  an  osteotomy  of  the  shaft  of  the  femur  near 
the  neck  is  necessary;  otherwise  a  transposition  will  take  place  as  the 
patient  turns  the  foot  outward.  The  immediate  result  of  the  operation 
is  good,  and  the  ultimate  results  are  in  a  large  number  of  cases  excel- 
lent. Transposition  takes  place  in  a  certain  percentage  of  cases,  due, 
probably,  to  a  twist  in  the  head  of  the  neck  which  is  overlooked  and 
not  corrected.  Rigid  asepsis  is  essential.  Re-establishment  of  motion 
can  be  obtained  unless  the  operative  intervention  causes  an  ankylosis 
from  extensive  operative  injury  to  the  acetabulum  and  the  head  of  the 
femur. 

The  limb  is  maintained  in  a  flexed  and  strongly  abducted  position 
by  means  of  a  plaster-of- Paris  spica  reaching  from  the  thorax  down  to 
the  foot.  Access  to  the  wound  is  obtained  by  means  of  a  window  cut 
in  the  plaster.  The  amount  of  abduction  necessary  at  the  outset  will 
vary  with  the  difficulty  in  keeping  the  bone  in  the  socket ;  the  limb  is 
gradually  adducted  by  means  of  subsequent  bandages. 

Where  there  is  much  change  in  the  obliquity  of  the  neck  of  the 
femur,  there  results  from  the  operation  a  coxa  vara  which  must  be  cor- 
rected by  operation  or  must  be  outgrown.  It  is  manifest  that  the  bone 
will  grow  in  better  shape  when  in  the  socket  than  out,  and  where  the 
operation  is  done  in  young  children,  successful  results  can  be  expected 
in  skilful  hands.  The  period  when  operation  is  advisable  is  between 
the  ages  of  three  and  eight  years.  Success  has  been  obtained  in  older 
cases,  and  less  marked  changes  in  the  head  of  the  femur  have  taken 
place.  The  results  in- double  cases  are  not  as  perfect  as  those  in  single, 
owing  to  the  difficulty  of  restoring  the  distorted  heads  and  necks  on 
both  sides  equally  in  distorted  acetabulum. 

Reduction  by  Forcible  Manipulation. — The  early  attempts  at  forci- 
ble reposition  under  an  anesthetic  in  congenital  dislocation  of  the  hip 
were  not  successful.  Guided  by  his  knowledge  of  the  pathology  of 
congenital  dislocations,  and  profiting  by  his  experience  in  reduction  after 
incision,  Lorenz  has  devised  a  so-called  bloodless  method  for  the  treat- 
ment of  these  cases.  This  method  has  had  sufficient  trial  to  demon- 
strate its  efficacy  in  certain  adapted  cases. 

Reduction  by  forcible  manipulation  can  be  successful  only  if  the 
head  of  the  femur  can  be  made  to  dilate  and  pass  through  the  neck  of 


CONGENITAL   DISLOCATION  OF  THE   HIP. 


755 


the  capsule  into  the  acetabulum,  accompanied  by  the  freeing  and  stretch- 
ing of  adherent  and  shortened  portions  of  the  capsule,  as  well  as  the 
lenothenine  of  certain  muscles.  In  children  over  two  and  under  five 
years — in  some  instances  between  five  and  seven  years — under  an  anes- 
thetic, forcible  reduction  can  be  successfully  used ;  but  in  some  in- 
stances it  is  by  no  means  certain  in  bloodless  reduction  that  a  portion 
of  the  distorted  capsule  may  not  be  folded  in  in  front  of  the  femur, 
making  a  relapse  probable. 

It  is  sometimes  advisable  as  a  preliminary  step  to  stretch  the  mus- 
cles, and  possibly  the  capsule.  For  this  purpose  the  child  is  placed 
upon  its  back  on  a  frame,  and  by  means  of  weights  and  pulleys  traction 
is  exerted  with  the  legs  abducted  more  and  more  as  the  muscles  yield. 
A  counter-pull  can  be  made  by  cross-straps  pressing  down  upon  the 
top  of  the  trochanter.  This  can  be  done  without  causing  the  patient 
great  discomfort,  and  a  position  of  forced  abduction  nearly  at  right 
angles  with  the  trunk  of  the  limb  can  be  gained  in  young  children  after 
a  short  time. 

After  this  preliminary  treatment  the  patient  should  be  anesthetized, 
and  then  considerable  force  should  be  exerted  by  the  hand,  by  means  of 


FlG.  371. — Method  of  forcible  stretching  under  anesthesia,  with  forcible  abduction  and  hyper- 
extension. 

apparatus  with  screw  or  windlass  attachments,  in  such  a  direction  as  to 
overcome  the  adhesions,  the  shortened  bands  of  capsule,  and  the  con- 
tracted muscles. 

The  child  is  placed  upon  its  back,  the  thigh  much  abducted,  and 
traction  exerted  by  means  of  a  loop  of  yarn  placed  around  the  ankle 
or  a  padded  anklet,  and  attached  to  a  screw-force  fastened  to  the  end 
of  the  table,  while  at  the  same  time  counter-traction  is  maintained  by 
means  of  a  long  sheet  of  folded  cloth  placed  beneath  the  perineum  on 
the  unaffected  side  ;  or  a  windlass-traction  attachment  can  be  added  to 
the  well-known  Thomas  knee-splint.  The  force  is  transmitted  to  the 
leg  through  strips  of  adhesive  plaster  applied  along  and  across  the  leg 
and  thigh,  firmly  bandaged  to  the  limb,  and  counter-resistance  is  met 
by  the  padded  ring  at  the  upper  end  of  the  splint  pressing  against  the 
tuberosity  of  the  ischium  and  ramus  of  the  pubes.  The  limb  is  to  be 
abducted  as  much  as  possible,  and  force  slowly  applied.  This  maneuver 
should  be  applied  in  various  directions,  stretching  the  adductor  muscles, 
the  flexors,  the  hamstrings  and  rectus  femoris,  and  the  capsule. 


75^  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

After  a  few  minutes  of  forced  mechanical  hyperabduction  with 
traction,  the  thigh  should  be  alternately  hyperextended,  abducted, 
rotated,  and  circumducted  in  order  to  loosen  all  portions  of  the  capsule. 
If  the  capsule  can  be  thus  sufficiently  stretched,  reduction  can  be 
affected  by  manipulation,  and  is  indicated  by  an  audible  movement  of 
the  head  of  the  femur  into  the  capsule  ;  otherwise  an  incision  will  be 
necessary  in  order  to  reduce  the  dislocation.  Tendency  to  recurrence 
justifies  further  attempts  at  stretching,  which  may  be  aided  by  using 
the  femur  as  a  lever,  provided  the  head  can  be  engaged  in  the  acetab- 
ular lip. 

After  bloodless  reduction  the  limb  should  be  strongly  flexed  and 
abducted,  and  kept  in  this  position  by  means  of  a  plaster-of- Paris  spica. 
From  time  to  time  new  bandages  are  applied  until  the  leg  assumes  a 
normal  position.  A  splint  can  be  combined  with  massage  for  several 
months,  and  the  protective  appliances  gradually  removed. 

After  bloodless  reduction  the  patient  should  be  allowed  to  walk 
about  on  the  abducted  limb  to  exert  pressure  upon  the  acetabulum,  to 
press  through  a  fold  of  the  capsule,  if  any  remain. 

The  amount  of  time  required  for  after-treatment  varies,  of  course, 
with  the  condition  of  the  anatomic  changes.  Where  there  is  a  thick  fold 
of  capsule  between  the  head  and  the  acetabulum,  the  expectation  is  that 
the  head  of  the  femur  shall  force  its  way  through  this  capsule,  and  an 
indeterminate  amount  of  time  is  needed  ;  but  in  cases  of  this  sort  opera- 
tion by  incision  is  probably  to  be  preferred.  Where  the  intercapsular  neck 
is  large  and  the  head  can  be  placed  well  into  the  acetabulum,  an  excel- 
lent result  can  be  expected ;  but  in  a  large  number  of  cases  relapses 
occur,  owing  to  the  defective  condition  of  the  capsule  and  to  the  shape 
of  the  head  of  the  femur. 

Neoarthrosis  Operation. — Certain  cases  resist  all  attempts  at 
reducing  and  maintaining  the  head  of  the  femur  in  the  acetabulum. 
Hoffa  has  proposed  an  operation  for  these  cases,  on  the  ground  that 
nature  never  forms  a  true  new  joint.  In  this  operation  the  capsule  is 
incised  and  the  bone  curetted  and  deepened  to  form  a  socket.  The 
value  of  this  method  has  not  yet  been  thoroughly  demonstrated. 

Excision  of  the  head  of  the  femur  does  not  seem  to  be  a  proper  pro- 
cedure in  congenital  dislocation. 

Gradual  Reduction  by  Mechanical  Appliances. — Gradual  reduction 
by  mechanical  appliances  has  not  proved  itself  a  reliable  method  of 
treatment ;  neither  has  the  method  of  reduction  by  long-continued  bed- 
traction. 

TALIPES  VALGUS. 

The  position  of  the  normal  foot,  whether  at  rest  or  in  action,  is 
regulated  by  certain  physiological  conditions,  which,  when  exaggerated 
or  persistent,  may  give  rise  to  the  affection  known  as  flat-foot.  If  the 
leg  and  foot  hang  loosely  from  the  knee,  the  anterior  border  of  the 
tibia  can  be  projected  in  a  relatively  straight  line  to  the  space  between 
the  first  and  second  toes.  If  the  individual  bears  his  weight  upon  the 
foot,  this  line  forms  an  obtuse  angle  near  the  internal  malleolus,  point- 
ing inward. 

This  anatomical  change  consists  of  a  twist  of  the  foot  at  the  medio- 


TALIPES    VALGUS.  757 

tarsal  articulation,  and  also  a  sagging  downward  (or  plantar  flexion)  of 
the  head  of  the  astragalus  and  the  os  calcis.  This  condition  is  exagger- 
ated when  the  weight  is  borne  on  one  foot  alone,  as  demonstrated  by 
foot-prints  on  smoked  paper.  The  bones  of  the  foot  are  arranged  so 
as  to  form  a  transverse  and  two  longitudinal  arches  sustained  by  liga- 
ments when  the  foot  is  at  rest,  and  supported,  in  addition,  by  muscles 
when  in  action.  The  addition  of  weight  causes  a  slight  lengthening 
and  widening  of  the  foot,  of  little  importance  compared  with  twist  at 
the  mediotarsal  articulation.  The  important  changes  take  place  in  the 
internal  longitudinal  arch. 

The  checks  to  the  mediotarsal  twist  are  largely  the  tibialis  anticus 
and  posticus  muscles,  but  also  the  plantar  fascia  and  plantar  muscles,  as 
well  as  the  flexors  of  the  toes,  the  various  ligamentous  bands  which  pass 
from  the  os  calcis  to  the  astragalus,  the  scaphoid  and  cuneiform  bones 
on  the  sole  of  the  foot,  and  the  strong  deltoid  ligament.  Within  certain 
limits  the  amount  of  change  varies  according  to  the  weight  of  the 
individual  in  relation  to  the  strength  of  his  muscles  and  ligaments. 
Deformity  alone  is  no  sign  of  suffering,  as  proved  by  athletes  accustomed 
to  bear  great  weights  ;  but  subjective  symptoms  arise  when  the  muscles 
weaken,  thereby  causing  the  ligaments  to  stretch.  Permanent  distor- 
tion follows  when  the  ligaments  are  lengthened,  and  in  extreme  cases 
the  relative  position  and  shape  of  the  tarsal  bones  become  altered  so 
that  complete  inversion  is  no  longer  possible.. 

.Etiology. — Anything  which  weakens  the  muscles  and  ligaments 
of  the  foot  or  disproportionately  increases  the  weight  to  be  overcome 
predisposes  to  the  development  of  flat-foot.  Furthermore,  imperfect 
shoeing  puts  the  foot  at  a  mechanical  disadvantage.  The  commonest 
faults  of  shoeing  are  pointed  toes,  high  heels,  short  shoes,  or  shoes 
arranged  so  that  the  toes  are  crowded. 

Symptoms  and  Diagnosis. — Flat-foot  gives  rise  to  but  few  symp- 
toms beyond  the  deformity,  the  peculiarity  of  gait,  and  fatigue  and  pain 
in  locomotion ;  but  this  chronic  condition  is  interrupted  at  times  by  a 
muscular  or  ligamentous  strain  which  causes  an  exaggeration  of  the 
peculiarity  in  gait,  and  may  give  rise  to  a  limp,  pain  and  a  puffiness  of 
the  dorsum  of  the  foot,  and  tonic  spasms  of  the  extensor  muscles  of 
the  foot.  The  deformity  of  well-marked  cases  is  characteristic.  The 
sinking  of  the  foot  shows  that  the  inner  arch  is  lower  than  normal,  and 
the  lack  of  elasticity  in  gait  is  easily  recognized,  as  well  as  abnormal 
eversion. 

More  care  is  needed  to  recognize  the  pathological  flat-foot  in  chil- 
dren or  in  the  lighter  stages  in  adults.  An  impression  of  the  sole- 
pressure  on  paper  blackened  by  camphor-soot,  first  with  but  little 
weight,  then  with  the  whole  weight  of  the  body,  is  of  value  to  indicate 
the  area  of  maximum  contact.  The  diminishing  extent  of  the  hollow 
under  the  inner  arch  is  indicative  of  the  flatness  of  the  foot. 

Treatment. — The  treatment  of  these  cases  necessarily  varies 
according  to  their  severity,  and  for  descriptive  purposes  we  will  con- 
sider these  stages  :  1.  Light  cases  in  growing  children  ;  2.  Severe  cases 
in  growing  children;  3.  Light  cases  in  adults;  4.  Severe  resistant  cases 
in  adults. 

In  the  light  cases  in  children  it  is  extremely  important  that  proper 


758  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

shoes  are  furnished.  The  best  covering  for  the  foot  is  necessarily  a 
shoe  which  constricts  as  little  as  possible.  It  is  essential  that  the  shoes 
be  not  too  short,  the  toes  broad,  heels  low.  The  soles  of  the  shoes 
and  the  uppers  should  be  shaped  so  that  the  toes  are  not  crowded  or 
forced  outward.  Short  stockings  are  injurious.  Gymnastic  exercises 
as  mentioned  for  adults  may  be  of  value. 

In  the  severer  cases  mechanical  support  for  the  arch  of  the  foot 
may  be  necessary.  In-soles  with  a  stiffened  or  padded  arch  of  sad- 
dler's felt  will  be  sufficient  in  the  lighter  cases,  with  or  without  the 
raising  of  the  inner  edge  of  the  sole  and  heel  from  \  to  \  inch,  for  the 
purpose  of  throwing  the  weight  more  upon  the  outer  side. 

In  light  cases  in  adults  supports  to  the  arch  are  more  necessary 
than  in  children,  on  account  of  the  increased  weight  and  strain.  Suit- 
able shoes  should  be  ordered,  and  gymnastic  exercises  prescribed  in 
order  to  develop  the  muscles  which  support  the  arch.  The  patient 
should  walk  with  the  toes  straight  ahead,  and  avoid  a  position  with  the 
foot  everted. 

In  light  cases  proper  shoes  are  sufficient  to  correct  the  difficulty; 
but  where  the  foot  is  badly  deformed,  and  the  amount  of  strain  brought 
upon  the   ligaments  is  great,  some   form  of  firm  plate  is  desirable  to 


Fig.  372. — Whitman's  brace  for  flat-foot. 

relieve  the  strain  of  the  patient  when  upon  the  foot  for  a  number  of 
hours.  The  plate  is  worn  inside  the  shoe,  which  should  be  of  an  ap- 
proved pattern.  The  most  efficient  plates  are  those  recommended  by 
Whitman  (Fig.  372).  The  plate  should  be  made  from  a  plaster  model 
of  the  foot  in  the  proper  position — i.  e.,  turned  slightly  inward.  The 
plate  should  not  be  so  long  as  to  reach  the  heads  of  the  metatarsal 
bones  or  the  tubercles  of  the  os  calcis,  but  it  should  support  the  under 
surface  of  the  scaphoid  and  the  head  of  the  astragalus.  The  metal  should 
be  strong  enough  not  to  yield  under  pressure. 

Excellent  plates  can  also  be  made  from  firm  celluloid,  softened  in 
boiling  water  and  manipulated  over  a  cast  by  the  hand  of  the  surgeon, 
protected  by  woolen  and  rubber  gloves. 

The  object  of  a  support  to  the  arch  is  partly  to  sustain  a  portion  of 
the  weight,  but  more  particularly  to  maintain  a  proper  position  of  the 
bones  of  the  foot. 

In  the  severer  cases,  accompanied  by  muscular  spasm  and  over- 


CLUB-FOOT,    OR    TALIPES  EQUINOVARUS.  759 

stretched  ligaments  in  the  fixed  eversion  of  the  foot,  it  is  necessary 
to  fix  the  foot  in  as  correct  a  position  as  possible  by  means  of  plaster 
bandages  successively  applied  to  the  foot,  using  in  some  instances 
force  under  an  anesthetic. 

The  treatment  as  mentioned  above  can  be  employed  as  soon  as  the 
patient's  feet  have  sufficiently  recovered.  In  certain  severe  cases  with 
marked  deformity  of  bone,  a  wedge-shaped  portion  can  with  benefit  be 
removed  from  the  neck  of  the  astragalus  or  scaphoid,  and  then  the  foot 
inverted  and  fixed  by  means  of  a  plaster  bandage,  with  the  ordinary 
treatment  for  flat-foot  for  the  stage  of  convalescence. 

The  prognosis  of  the  treatment  of  flat-foot  is  satisfactory. 

CLUB-FOOT,  OR  TALIPES  EQUINOVARUS. 

Club-foot  consists  of  a  dislocation  at  the  mediotarsal  articulation, 
with  resulting  changes  in  soft  tissues  (skin,  muscles,  tendons,  fasciae) 
and  bones  or  cartilages.  The  anterior  part  of  the  foot  is  inverted  and 
twisted,  and  the  heel  elevated  so  that  the  patient  walks  on  the  outside 
and,  in  extreme  cases,  on  the  dorsum  of  the  foot.  The  soft  tissues 
especially  involved  are  the  abductor  pollicis  muscle,  the  tibialis  anticus 
and  posticus,  plantar  fascia,  plantar  and  astragaloscaphoid  ligaments, 
and  tendo  Achillis.  The  bony  deformity  of  importance  consists  of  an 
inward  rotation  of  the  scaphoid  and  cuboid  bones  around  the  anterior 
surfaces  of  the  astragalus  and  os  calcis  respectively,  with  occasional 
deformity  of  the  astragalus  and  os  calcis.  Secondary  changes  may  be 
the  result  of  pressure  or  locomotion. 

Club-foot  may  be  congenital  or  acquired.  The  cause  of  the  con- 
genital variety  is  still  a  matter  of  theory ;  the  acquired  variety  is  almost 
always  secondary  to  infantile  paralysis,  and  it  will  not  be  further  con- 
sidered here.  In  congenital  club-foot  the  muscles  may  atrophy  from 
disuse,  but  are  never  paralyzed. 

Symptoms  and  Diagnosis. — These  patients  suffer  considerable 
inconvenience  in  walking,  and  the  gait  is  unsightly  and  characteristic 
when  the  deformity  is  double,  in  that  one  foot  is  lifted  over  the  other 
in  a  peculiar  manner.  Bursas  and  callosities  frequently  develop,  and 
they  may  be  the  seat  of  inflammatory  processes.  The  position  of  the 
foot  and  the  shortened  ligaments  are  characteristic.  By  manipulation 
it  may  be  possible  to  reduce  the  deformity  more  or  less,  but  it  will 
recur  at  once.  The  deformity  increases  as  the  patient  walks  upon  the 
distorted  foot. 

Prognosis. — The  deformity  usually  persists  or  increases  if 
untreated,  and  shows  no  tendency  to  correct  itself.  Early  cases  are 
easier  to  correct  than  late  ones.  All  cases  are  amenable  to  correction, 
and  the  deformity  will  not  recur  if  complete  correction  or  overcorrec- 
tion has  been  secured  for  a  sufficiently  long  period  to  enable  the  parts 
to  have  adjusted  themselves. 

Treatment. — The  treatment  will  vary  according  to  the  age  and 
condition  of  the  deformity,  and  should  be  begun  as  soon  as  the  nutri- 
tion of  the  child  is  such  that  treatment  can  be  continued  without  inter- 
ruption. Methods  should  be  tried  in  the  order  of  their  simplicity,  as 
a  general  rule.     The  aim  should  be  to  overcorrect  the  deformity,  and 


760 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


retain  the  foot  in  the  corrected  position  until  all  parts  become  adjusted, 
and  there  is  no  tendency  to  recurrence  when  the  foot  is  at  rest  and 
influenced  only  by  gravity,  and  particularly  when  in  walking  it  does 
not  tend  to  assume  its  former  distorted  position. 

All  treatment  is  mechanical,  with  or  without  some  surgical  interfer- 
ence, but  electricity  and  massage  may  be  of  value  during  convales- 
cence. 

Infantile  Cases. — Here  the  foot  is  pliable,  and  the  chief  obstacles 
to  correction  are  the  shortened  muscles  and  ligaments.  Gradual  cor- 
rection by  means  of  manual  force  and  repeated  plaster  bandages  can 
be  employed,  although  often  tedious. 

The  deformity  is  corrected  in  this  order :  Inversion  at  the  ankle- 
joint,  inversion  at  the  mediotarsal  joint  (varus),  and  finally  the  plantar 


Fig.  373. — -Side  view  of  the  retention 
apparatus  applied  inside  of  the  leg. 


FlG.  374. — .Side  view  of  the  retention  appliance  : 
outside  view,  showing  the  leather  side-piece,  with 
metal  ring  through  which  the  strap  passes,  exert- 
ing side-pressure  upon  the  os  calcis. 


flexion  (equinus).  Plaster  bandages  are  applied  over  a  limb  well  pro- 
tected with  cotton,  every  two  to  four  weeks,  extending  from  the  toes 
to  the  thigh,  with  the  knee  slightly  bent  in  order  to  retain  the  plaster 
without  slipping.  In  correcting  the  deformity  care  must  be  exercised 
that  the  cuboid  is  forced  outward  as  well  as  the  scaphoid,  and  that  the 
heads  of  the  os  calcis  and  astragalus  are  forced  inward ;  otherwise  the 
correction  is  only  apparent,  and  will  not  be  permanent. 

Sooner  or  later,  according  to  the  condition  of  the  foot  and  the  cir- 
cumstances of  the  case,  tenotomy  is  resorted  to  in  order  to  free  what- 
ever bands  may  be  necessary,  particularly  the  tendo  Achillis.  After 
the  operation  the  foot  is  retained  ten  days  to  two  weeks  in  a  plaster- 
of-Paris  bandage,  and  then  a  varus  shoe  is  fitted  to  the  foot.  The  inside 
support  answers  the  purpose  thoroughly,  but  it  needs  to  be  modified 
to  each  case  and  requires  careful  attention.     Straps  and  buckles  of  this 


CLUB-FOOT,    OR    TALIPES  EQUINO  VARUS. 


761 


appliance  will  answer  in  careful  hands  to  secure  the  foot,  but  in  order 
to  prevent  slipping,  the  foot  may  be  held  firmly  to  the  padded  foot- 
plate of  this  appliance  by  means  of  a  plaster  or  silicate  bandage ;  or 
— which  requires  less  watching  than  when  straps  and  buckles  are  used ; 
plaster  bandages  may  be  employed  for  a  long  period.  The  splint  must 
be  so  arranged  as  to  allow  motion  of  the  foot  except  inversion  and 
plantar  flexion  beyond  a  right  angle,  and  care  must  be  taken  that  the 
external  pressure  is  on  the  head  of  the  os  calcis,  and  not  on  the  cuboid 
bone.  The  splint  can  be  worn  inside  of  a  shoe,  laced  to  the  toe,  and 
should  be  worn  for  a  period  sufficiently  long  to  ensure  moulding  of  the 
bones  and  tissues  into  a  normal  shape. 

Where  a  splint  of  this  sort  is  used,  it  is  necessary  that  it  should  be 
curved  sufficiently  to  allow  the  inner  malleolus  to  be  dropped  or  forced 
to  the  inside  more  than  is  normal,  in  order  to  allow  for  overcorrection. 


Fig.  375- — a,  Sole-plate  of  retention-shoe;  b,  side  view  of  sole-plate  of  retention-shoe,  with 
securing  clasp  (d )  and  metal  loops  (e,  e)  for  steadying  straps  ;  c,  upright. 

A  subsequent  operation  is  necessary  if  any  fibers  remain  undivided, 
and  in  case  of  imperfect  correction.  Before  the  child  is  three  years 
of  age  all  deformity  should  be  corrected. 

Older  Cases  (three  to  six  years). — In  these  cases  the  judgment  of 
the  surgeon  must  be  exercised  to  a  greater  extent.  Immediate  over- 
correction is  called  for  by  both  manual  and  operative  measures,  becom- 
ing more  and  more  radical  until  the  desired  end  is  reached.  In  mild 
cases  tenotomy  of  the  tibiales,  the  plantar  fascia,  and  tendo  Achillis, 
and  forcible  correction  by  means  of  the  hand  or  a  wrench,  will  suffice ; 
but  if  this  fails,  an  open  incision  according  to  the  method  recommended 
by  Phelps  must  be  made  on  the  inner  side  of  the  foot,  and  all  resistant 
structures  divided.  These  procedures  will  correct  most  cases,  and  the 
retention  treatment  by  means  of  plaster-of-Paris  bandages  and  the 
varus  shoe  is  the  same  as  for  the  infantile  variety. 

When  extensive  alteration  in  the  neck  of  the  astragalus  or  the  os 
calcis  exists,  an  osteotomy  of  the  neck  of  one  or  both  of  these  bones 


762  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

is  advisable,  even  in  young  children,  and  the  results  are  far  more  satis- 
factory than  those  following  excision  of  the  astragalus  or  exsection  of 
a  portion  of  the  tarsus — procedures  involving  unnecessary  sacrifice  of 
bone.     In  brief,  the  operation  is  as  follows  : 

All  internal  bands  having  been  previously  divided,  a  curved  incision 
is  made,  starting  from  the  external  malleolus,  curving  over  the  head  of 
the  os  calcis  and  then  down  to  the  sole  of  the  foot,  and  the  flap  re- 
flected downward.  The  peronei  tendons  are  turned  aside  or  severed 
(to  be  sutured  later),  and  on  exposure  of  the  neck  of  the  os  calcis  it  is 
chiselled  through  and  a  wedge-shaped  piece  of  bone  removed.  The 
articular  surface  is  not  to  be  disturbed.  This  allows  the  cuboid  bone 
to  be  forced  out  and  up,  and  the  foot  to  be  corrected.  In  addition,  in 
some  cases  the  neck  of  the  astragalus  is  to  be  divided  by  a  linear  or 
wedge-shaped  osteotomy,  if  necessary.  Perfect  asepsis  is  demanded. 
When  a  good  position  is  assured  it  is  maintained  by  means  of  a  plaster 
bandage.  The  after-treatment  consists  of  a  properly  fitted  varus  shoe, 
with  counterpressure  over  the  heads  of  the  astragalus  and  os  calcis, 
and  not  on  the  cuboid  bone,  to  be  worn  inside  of  the  shoe  for  at  least 
six  months. 

Adult  Cases. — The  ordinary  measures  are  of  no  avail  in  these 
cases,  on  account  of  bony  deformity  and  the  presence  of  firm  liga- 
mentous bands.  Radical  treatment  should  be  attempted  at  once,  and 
the  most  favorable  results  are  obtained  after  osteotomy  of  the  astraga- 
lus and  os  calcis,  as  just  described,  though  the  removal  of  a  large 
wedge  of  bone  is  needed.  Convalescence  is  more  rapid  in  these  cases, 
and  the  apparatus-wearing  period  shorter,  for  the  weight  and  intelli- 
gence of  the  individual  in  using  the  foot  are  of  much  service. 

In  general,  convalescent  treatment  may  be  summarized  thus  :  In 
infantile  cases,  after  complete  correction,  retention  apparatus  night  and 
day  for  six  months,  walking  appliance  one  to  two  years  longer. 

In  children  under  five  years,  same  precautions,  except  that  walking 
appliances  are  needed  longer. 

In  adults,  following  tenotomy,  walking  appliances  about  one  year. 
After  osteotomy,  the  same  for  about  six  months. 


CHAPTER    XXIII. 
SURGERY  OF  THE  MUSCLES,  TENDONS,  AND  BURSAE. 

INJURIES  OF  MUSCLES  AND  TENDONS. 

The  most  superficial  muscles  and  tendons  are  naturally  the  most 
liable  to  injury,  the  principal  injuries  to  which  they  are  subject  being 
contusions,  sprains,  rupture,  wounds,  etc. 

Contusions  of  Muscles. — Contusions  of  muscles  are  of  frequent 
occurrence,  and  are  usually  caused  by  blows  or  falls.  A  contusion 
may  exist  in  any  degree  of  severity,  from  a  simple  injury  of  a  few 
muscular  fibers  to  an  extensive  destruction  of  muscular  tissue.  On 
account  of  the  hemorrhage  which  invariably  takes  place  in  all  contu- 
sions, more  or  less  blood  accumulates  at  the  seat  of  injury — so  much, 
indeed,  in  some  cases,  as  to  form  a  distinct  hematoma.  Although  con- 
tusions of  muscles  are  generally  simple,  they  frequently  accompany 
severer  injuries,  such  as  fractures,  dislocations,  etc. 

Signs. — The  injury  is  recognized  by  pain  and  tenderness  over  the 
affected  area,  with  some  loss  of  power  in  the  part.  Passive  motion 
usually  causes  considerable  pain.  Ecchymosis  and  swelling  are  quite 
certain  to  be  evident  sooner  or  later.  Before  making  a  diagnosis  of 
simple  contusion,  it  is  well  to  exclude  by  careful  examination  the  more 
serious  conditions,  such  as  fracture,  dislocation,  etc.,  which  it  may 
accompany. 

Prognosis. — The  outlook  is  favorable  in  most  cases  for  a  return  to 
healthy  conditions.  The  extravasated  blood  and  the  debris  of  muscular 
tissue  are  absorbed,  and  connective  tissue  replaces  them.  In  some 
cases  atrophy  of  the  muscular  fibers  takes  place,  resulting  in  loss  of 
power  sometimes  so  persistent  as  to  suggest  the  possibility  of  injury 
to  the  nerve.     Occasionally  suppuration   occurs. 

Treatment — The  object  of  treatment  is  to  arrest  bleeding,  to  cause 
absorption  of  extravasated  products,  and  to  prevent  suppuration.  The 
principal  means  at  our  disposal  are  (i)  rest,  (2)  elevation  of  the  part, 
(3)  compression,  and  (4)  cold.  Where  the  injury  is  slight,  all  that  may 
be  necessary  is  to  put  the  part  at  rest,  to  support  and  immobilize  it  by 
bandages,  etc. ;  but  in  the  more  serious  cases  the  patient  should  be  put 
to  bed,  and  the  affected  part  raised,  if  possible,  so  as  to  limit  the 
amount  of  blood  going  to  it.  Cold  (best  applied  in  the  form  of  ice- 
bags)  may  be  used  with  advantage,  especially  when  there  is  a  tendency 
to  hematoma.  As  the  latter,  when  it  is  large,  requires  a  long  time  for 
absorption,  and  furnishes  a  good  opportunity  for  suppuration,  it  is 
occasionally  advisable  in  the  early  stages  to  wash  out  the  clot  through 
a  small  incision.  If  suppuration  takes  place,  early  incision  and  thor- 
ough cleansing  of  the  cavity  are  called  for. 

763 


764  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Sprains  and  Strains  of  Mnscles  and  Tendons. — A  sprain  or 
strain  of  a  muscle  or  tendon  usually  means  the  injury  resulting  from 
(1)  an  undue  stretching  from  external  violence,  (2)  sudden  or  violent 
contraction  of  the  muscle,  or  (3)  the  continued  overuse  of  one  muscle 
or  group  of  muscles. 

Signs. — The  affected  muscle  is  usually  painful  and  tender,  and  has 
lost  a  certain  amount  of  its  power.  The  pain  and  tenderness  may  be 
felt  at  any  part  of  the  muscle  itself,  or  at  the  point  of  insertion  of  the 
tendon.     Occasionally  there  is  some  ecchymosis. 

Prognosis. — The  condition  is  not  usually  a  serious  one,  although  in 
certain  cases,  in  spite  of  the  most  approved  treatment,  some  of  the 
symptoms  persist  indefinitely.  This  is  particularly  true  in  sprains  of 
the  small  of  the  back,  the  shoulder,  hip,  etc. 

Treatment. — The  special  objects  of  treatment  are  to  relieve  pain 
and  to  restore  the  lost  tone  of  the  muscle.  These  are  effected  by 
resting  the  part  and  by  carefully  graduated  compression.  Massage  is 
frequently  useful,  and  sometimes,  especially  in  the  later  stages,  counter- 
irritation  may  be  of  advantage. 

Occasionally  one  sees  cases  of  what  are  called  "  chronic  sprains  "  or 
"  strains,"  caused  by  the  overuse  of  certain  muscles,  where  the  pain  is 
principally  at  the  origin  or  insertion  of  the  muscles.  Tenderness  and 
stiffness  are  prominent  symptoms.  Examples  of  this  are  seen  in  the 
so-called  base-ball  pitchers'  arm,  tennis-elbow,  etc.  Persistent  overuse 
of  a  muscle  may  give  rise  to  a  local  periostitis  at  one  of  the  points  of 
attachment  of  the  muscle,  possibly  resulting  in  necrosis  (see  cases 
recorded  by  Paget).  Occasionally,  as  a  result  of  these  repeated  strains, 
an  ossification  of  muscle  or  tendon  may  take  place  at  one  of  its  points 
of  attachment  to  the  bone.  The  best  instance  of  this  is  what  is  known 
as  "  riders'  bone,"  which  is  a  core  of  ossification  within  the  tendon  of 
the  adductor  longus,  in  men  who  are  much  on  horseback. 

Rupture  of  Muscles  and  Tendons. — Muscles  and  tendons  are 
ruptured  not  infrequently  as  a  result  of  some  sudden  and  violent  mus- 
cular contraction.  This  may  take  place  in  persons  in  the  vigor  of 
youth,  but  is  more  apt  to  occur  in  those  of  middle  or  advanced  age, 
whose  tissues  have  lost  some  of  their  elasticity,  and  especially  in  cases 
where  the  muscles  have  become  degenerated  by  long  and  exhausting 
illness.  The  rupture  of  muscle  may  be  partial  or  complete.  The 
investing  fascia  of  the  muscle  alone  may  be  ruptured,  allowing  protru- 
sion of  the  muscular  tissue  through  the  gap  thus  made  (hernia  of 
muscle),  or  the  muscle  itself  may  be  partly  torn  through,  or  may  be 
ruptured  through  its  entire  thickness,  in  which  case  there  is  a  pro- 
nounced retraction  of  both  ends.  When  a  tendon  ruptures,  the  con- 
traction of  its  muscle-belly  draws  the  fragment  attached  to  it  away 
from  the  other  fragment.  In  any  of  these  injuries  more  or  less  blood 
escapes  into  the  tissues. 

Signs. — During  effort  a  sudden  sharp  pain  is  felt,  followed  at  once  by 
a  feeling  of  helplessness  in  the  part.  The  site  of  the  injury  is  tender, 
and  in  most  cases  a  gap  can  be  seen  or  felt  there.  Sooner  or  later 
there  will  probably  be  swelling  and  some  ecchymoses — the  latter  often 
directed  by  the  fasciae  to  a  point  at  some  distance  from  the  seat  of  injury. 

Treatment. — The  principal  object  of  treatment  being  to  restore  as 


IXJURIES   OF  MUSCLES  AXD    TEXDOXS. 


765 


nearly  as  possible  the  continuity  of  the  ruptured  structure,  the  part 
should  usually  be  placed  at  rest,  by  bandages,  splints,  etc.,  in  such 
position  as  to  relax  the  muscle  most  thoroughly  and  approximate  the 
torn  ends,  and  ice-bags  should  be  applied.  In  suitable  cases  the  torn 
muscle  or  tendon  may  be  united  by  suture  (preferably  chromicized  cat- 
gut, or  kangaroo  tendon),  after  which  the  part  should  be  placed  in  the 
position  of  greatest  relaxation  for  the  muscle.  In  either  case  massage 
or  electricity  will  usually  be  found  of  benefit  in  the  later  stages.  Suture 
of  muscle  should  never  be  tried  if  there  is  reason  to  suppose  that  the 
muscular  tissue  is  degenerated.  Primary  suture  of  ruptured  tendons 
is  generally,  and  even  secondary  suture  is  often,  successful. 

Rupture  of  the  plantaris  is  not  uncommon.  This  muscle  arises 
from  the  back  of  the  femur  just  above  the  external  condyle,  and  is 
inserted  into  the  posterior  surface  of  the  os  calcis.  It  is  analogous  to 
the  palmaris  longus,  and,  like  that  muscle,  is  occasionally  absent.  The 
muscular  belly  (about  3  01-4  inches  long)  is  inserted  into  a  long,  narrow 
tendon.  During  a  sudden  motion,  as  in  lawn-tennis,  wrestling,  boxing, 
etc.,  a  sharp  stinging  pain  is  felt  in  the  calf,  like  a  whip-stroke.  The 
part  is  tender,  and  soon  becomes  swollen,  and  probably  ecchymosed. 
The  ecchymosis  may  be  about  the  ankle  rather  than  at  the  point  of 
rupture.  The  patient  should  be  put  to  bed  and  the  leg  immobilized 
on  a  ham-splint.  In  a  few  days  he  may  get  up  and  walk  (at  first 
with  crutches  or  cane)  keeping  the  heel  to  the  ground.  The  injury  is 
of  no  great  consequence,  and  the  patient  will  probably  recover  entirely 
in  a  couple  of  weeks  or  so. 


Fig.  376. —  Rupture  of  the  tendon  of  the  long  head  of  the  biceps. 


Rupture  of  the  Biceps  of  the  Arm. — Though  the  muscle  itself  is 
rarely  ruptured,  its  tendons  are  more  frequently  the  seat  of  this  injury 
than  is  generally  supposed.  Loos 1  has  collected  sixty-two  recorded 
cases.     The  long   tendon   which  arises   from  the  upper  border  of  the 

1  Beifra<re  z.  klin.  Chir.,  xxix.,  Heft  2. 


766 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


glenoid  fossa  is  most  frequently  ruptured  of  all  the  parts  of  this  muscle, 
and  this  is  especially  liable  to  occur  where  the  tendon  has  been  worn 
to  a  thin  ribbon,  as  in  cases  of  rheumatoid  arthritis  of  the  shoulder- 
joint.  It  generally  gives  way  in  such  cases  at  or  close  to  its  origin  and 
slides  down  the  bicipital  groove,  where  in  time  it  acquires  a  new 
attachment.  During  unusual  exertion  in  lifting,  a  snap  is  felt  by  the 
patient,  as  of  something  giving  way,  and  the  arm  falls  helpless.  The 
arm  cannot  be  flexed  voluntarily  at  the  elbow,  the  attempt  to  do  so 
causing  pain  referred  to  the  shoulder  and  along  the  bicipital  groove. 
This  region  is  very  tender  and  may  be  ecchymosed.  The  deformity  is 
characteristic.  The  muscular  belly  of  the  biceps  is  unduly  prominent, 
but  is  soft  and  flabby  to  the  touch.  The  outer  head  of  the  muscle  has 
collapsed  downward,  and  just  below  the  lower  margin  of  the  deltoid 
there  is  an  unnatural  depression  (Fig.  376)  in  which,  by  deep  pressure, 
the  lower  end  of  the  prolapsed  tendon  can  be  felt. 

The  arm  should  be  bandaged  from  the  fingers  to  the  shoulder  and 
placed  in  a  sling. 

When  the  tendon  of  insertion  is  ruptured,  it  is  most  frequently  torn 
away  from  its  insertion  into  the  tubercle  of  the  radius.     The  injury  may 


Fig.  377. — Rupture  of  the  tendon  of  insertion  of  the  biceps  (author's  case). 


be  recognized  by  the  history  of  the  case  and  by  the  existence  of  a 
transverse  gap  across  the  front  of  the  arm  just  above  the  elbow  (Fig. 
377).  In  such  a  case  an  attempt  should  be  made  by  open  incision  to 
stitch  the  two  ends  together.  The  writer  was  once  obliged  to  sew  the 
tendon  to  the  brachialis  anticus  beneath  it,  as  the  entire  tendon  had 
been  torn  away  from  the  bone.  The  arm  should  be  kept  in  a  position 
of  acute  flexion,  with  supinated  forearm,  for  three  or  four  weeks,  after 
which  passive  motion  and  massage  may  be  started.     The  short  head 


INJURIES    OF  MUSCLES  AND    TENDONS. 


767 


of  the  biceps  is  rarely  ruptured,  and 
still  more  rarely  the  belly  of  the 
muscle  itself. 

Rupture  of  the  Tendon  of  the 
Quadriceps  Extensor.  —  Rupture 
of  the  tendon  of  the  quadriceps  just 
above  the  patella  is  caused  by  the 
same  forces  that  cause  a  fracture  of 
the  patella  itself.  There  is  a  violent 
action  of  the  muscle  when  the  knee 
is  slightly  bent.  The  patient  ex- 
periences a  sudden  pain,  and  he 
cannot  stand  or  extend  his  thigh. 
There  is  a  marked  transverse  gap 
across  the  front  of  thigh  just  above 
the  patella,  made  more  evident  by 
the  bunch  of  contracted  muscle 
above  it  (Fig.  378).  It  is  well  to 
bear  in  mind,  however,  that  this 
characteristic  deformity  in  certain 
cases  may  be  masked  by  a  pro- 
nounced synovial  effusion.  An  attempt  should  be  made  to  stitch 
together  the  torn  ends   of  the  tendon,  as  otherwise  the  disability  is 


Fig.   378.— Rupture   of    the    tendon   of    the 
quadriceps  extensor. 


Fig.  379. — Drawing  from  a  specimen  in  the  Warren  Museum  at  the  Harvard  Medical  School, 
Boston.  A  ring  which  the  person  wore  on  the  little  finger  caught  on  a  nail,  and  the  end  of 
the  finger  was  torn  off,  bringing  with  it  the  flexor  tendon. i 


pretty  sure  to  be  total  and  permanent.     After  this  the  leg  should  be 
kept  in  position  of  extension  for  several  weeks. 

Rupture  of  Other  Muscles  and  Tendons. — Rupture  of  the  lig amen- 

1  A  case  of  this  kind,  where  the  little  finger  of  an  infant,  twenty  months  old,  was  pulled  off 
by  being  caught  in  the  jamb  of  a  door,  was  seen  by  the  author  in  November,  1900,  and  reported, 
together  with  other  cases  of  this  injury,  in  the  Boston  Med.  and  Surg.  Jour,  of  Feb.  28,  1901. 


768  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

turn  patella  is  occasionally  met  with.  If  it  is  found  possible  to  do  so,  it 
should  always  be  united  by  sutures.  The  tendo  Achillis  may  be  rup- 
tured— an  injury  easily  recognized.  The  torn  ends  should  be  stitched 
together,  the  knee  strongly  flexed,  and  the  foot  extended,  and  this  posi- 
tion maintained  for  three  or  four  weeks.  The  sternomastoid  of  the 
child  has  been  ruptured,  partially  or  completely,  by  the  use  of  instru- 
ments in  difficult  labors  ;  the  rectus  abdominis  in  parturition  and  in 
tetanus  ;  some  of  the  flexors  of  the  forearm  in  athletic  sports  ;  and  the 
adductors  of  the  thigh  in  spasmodic  efforts,  during  riding,  to  retain  the 
seat  in  the  saddle.  The  extensor  tendon  of  a  finger  may  give  way  near  its 
insertion.    The  triceps  of  the  arm  and  the  psoas  have  also  been  ruptured. 

Thus  far  mention  has  been  made  of  rupture  principally  by  voluntary 
effort ;  but  muscles  and  tendons  may  be  extensively  torn  in  dislocations 
and  in  fractures  by  splinters  of  bone.  Tendons  may  be  pulled  away 
from  their  muscles,  as  is  occasionally  seen  when  a  finger  is  torn  off  by 
machinery,  bringing  with  it  one  or  more  of  the  long  tendons  which  are 
inserted  into  it  (Fig.  379). 

The  fiat  abdominal  muscles  may  be  ruptured  by  extreme  violence, 
even  when  the  skin  is  not  torn  through,  as  when  a  wagon-pole  is  driven 
with  great  force  into  the  abdomen.  In  case  the  person  survives  the 
injury,  ventral  hernia  is  the  probable  result. 

Dislocation  of  Tendons. — A  dislocation  of  a  tendon  is  an  uncom- 
mon accident.  It  occurs  perhaps  most  frequently  to  the  peroneal  ten- 
dons, which  may  become  dislocated  from  their  groove  behind  the  exter- 
nal malleolus.  This  dislocation  is  easy  to  reduce  by  extending  the 
foot  and  manipulating  the  relaxed  tendons  back  into  place.  Once 
reduced,  however,  they  have  a  constant  tendency  to  spring  out  again, 
and  an  operation  may  be  called  for  to  narrow  the  enlarged  sheath  or  to 
deepen  or  reconstruct  the  bony  groove,  bridging  it  over  with  fascia.  A 
few  cases  have  been  reported  of  dislocation  of  the  tendon  of  the  long  head 
of  the  biceps,  though  it  would  hardly  seem  as  if  this  injur}-  were  an 
anatomical  possibility.  During  a  sudden  and  violent  twist  of  the  arm 
the  tendon  slips  out  of  its  groove  to  the  inner  side,  causing  a  sickening 
pain,  with  immediate  loss  of  power.  If  the  muscle  is  relaxed  and  the 
part  manipulated,  the  tendon  springs  back  into  place  and  full  power  is 
at  once  regained.  Dislocations  have  also  been  reported  of  the  tendons 
of  the  tibialis  posticus,  sartorius,  extensors  of  the  fingers,  etc. 

Wounds  of  Muscles. — Muscles  are  frequently  wounded,  as  in 
accidents,  assaults,  operations,  etc.  Such  wounds  may  be  punctured, 
incised,  contused,  or  lacerated.  The  injured  muscle  can  usually  be  seen 
in  the  open  wound. 

Treatment. — The  entire  wound  and  the  skin  for  a  considerable  area 
about  it  should  be  thoroughly  cleansed  and  rendered  aseptic.  The 
wound  should  then  be  inspected,  any  foreign  bodies  which  may 
have  lodged  there  removed,  and  shreds  of  tissue  which  are  only  par- 
tially attached  should  be  trimmed  off.  If  the  muscular  fibers  have  drawn 
away  from  one  another,  leaving  a  gap,  an  attempt  may  be  made  to  unite 
them  by  animal  suture  (preferably  catgut),  and  the  skin  stitched  together 
over  them.  Wounds  which  are  too  small  to  be  properly  inspected  may 
be  cleansed  by  irrigation  and  the  curet,  or  may  be  freely  laid  open 
and  treated  on  the  general  plan  outlined  above. 


I XJ CRIES   OF  MUSCLES  AND    TENDONS.  769 

Wounds  of  Tendons. — As  is  the  case  in  muscles,  the  tendons 
that  are  most  often  wounded  lie  nearest  to  the  surface,  and  it  is  for  this 
reason  that  the  tendons  about  the  wrist  and  hand,  ankle  and  foot,  most 
frequently  suffer  in  this  way.  A  wound  in  a  tendon  is  usually  incised 
or  lacerated. 

Diagnosis. — In  case  a  wound  is  near  a  tendon,  the  diagnosis  of  sev- 
ered tendon  is  highly  probable  when  there  is  complete  loss  of  power  in 
the  part  to  which  the  tendon  goes  ;  but  a  positive  diagnosis  can  hardly 
be  made  unless  at  least  one  end  of  the  divided  tendon  is  seen. 

Treatment. — When  a  tendon  is  completely  divided,  the  only  rational 
treatment  is  to  find  the  ends,  bring  them  together,  and  stitch  them.  It 
is  highly  important  that  as  nearly  as  possible  the  normal  length  of  the 
tendon  and  its  original  mobility  should  be  preserved.  An  anesthetic 
should  be  given  to  the  patient  and  a  tourniquet  applied,  after  which 
the  wound  should  be  thoroughly  cleansed  and  examined.  If  both  ends 
of  the  tendon  are  not  at  once  visible,  the  limb  should  be  placed  in  such 
a  position  as  to  relax  the  muscle  to  which  the  tendon  belongs.  It  is, 
as  a  rule,  easy  to  find  the  distal  end  of  the  tendon,  but  the  proximal 
end  is  usually  pulled  away  from  the  wound  by  its  muscle.  This  end 
is  usually  found  by  enlarging  the  wound  in  the  direction  in  which  the 
tendon  probably  lies;  but  this  method  has  the  objection  that  the  scar 
resulting  from  such  a  cut  would  presumably  increase  the  liability 
of  adhesions,  and  thus  limit  the  subsequent  mobility  of  the  tendon. 
Several  methods  have  therefore  been  devised  for  finding  the  proximal 
end.  Perhaps  the  best  of  them  is  division  of  the  skin  and  underlying 
tissue  at  some  distance  from  the  wound,  in  the  presumed  direction  of 
the  tendon.  After  the  tendon  has  been  found  and  identified  the  sheath 
is  cautiously  opened  and  the  end  of  the  tendon  drawn  out  through  it 
and  fastened  to  the  eye  of  a  probe  which  has  been  passed  from  the 
original  wound.  This  end  can  then  be  pulled  into  the  original  wound 
and  stitched  to  the  distal  end  with  silk  or  chromicized  catgut.  A  stay- 
suture  may  be   used   if  the  tension  is   considerable  (Figs.    380,   381). 


!-= 

1 
1 
1 
1 
1 

=i 

I 

1 

1 

L — 

1 

Fig.  380. —  Simple  suture  of  divided  tendon.  FlG.  381— Suture  of  the  tendon  with  rein- 

forcement. 

The  skin  should  then  be  united  with  sutures,  and  the  part  kept  in  such 
a  position  as  to  secure  the  greatest  amount  of  relaxation  for  the  muscle. 
Drainage  is  usually  not  necessary.  When  there  is  a  gap  between  the 
two  ends  of  the  tendon  from  loss  of  substance,  a  bridge  between  them 
may  be  made  in  the  manner 
shown  in  the  accompanying 
illustration  (Fig.  382). 

Tendons  from  animals  have 

been     grafted     into    such    gaps      FlG.  382._Method  of  lengthening  divided  tendon. 
with  success,  and   Gluck  was 

equally  fortunate  with  strands  of  fine  catgut.     In  three  or  four  weeks 
after  the  operation  massage  and  passive  motion   may  be  begun,  and 
49 


J  JO  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

should  be  faithfully  carried  on  for  months.  The  functional  results 
obtained  in  such  cases  are  usually  very  satisfactory,  occasionally  even 
when  suppuration  has  occurred.  There  is  often  great  difficulty,  when 
several  tendons  are  divided,  in  properly  matching  them  ;  in  fact,  in  some 
cases  of  wounds  across  the  wrist  it  is  well-nigh  impossible  to  do  so. 
Secondary  suture  of  tendons  has  also  been  attended  with  considerable 
success.  In  such  cases  there  is  always  a  gap  to  be  bridged  over, 
owing  to  the  fact  that  there  is  usually  a  mass  of  cicatricial  tissue  to  be 
removed  before  the  ends  of  the  tendon  can  be  sutured. 

DISEASES  OF  MUSCLES. 

Inflammation  of  Muscle  (Myositis). — This  usually  appears  in 
a  subacute  or  chronic  form,  and  is  due  to  injury,  overwork,  exposure  to 
cold  and  wet,  or  rheumatism.  It  also  may  result  from  inflammation 
spreading  from  contiguous  tissue.  There  is  usually  an  exudation 
between  the  muscular  fibers,  which  in  the  less  severe  forms  is  absorbed, 
but  in  the  more  persistent  ones  organizes  and  later  contracts,  thus 
causing  real  atrophy  of  the  muscular  fibers  themselves.  Occasion- 
ally the  inflammation  may  advance  to  suppuration.  In  very  rare 
instances  ossification  takes  place  in  various  muscles  in  the  body  (myo- 
sitis ossificans).  The  cause  and  pathology  of  this  disease  are  as  yet 
unknown. 

Symptoms. — Pain  and  stiffness  are  prominent  symptoms.  The  pain 
is  often  severe,  especially  at  night.  The  area  over  the  affected  muscle 
is  extremely  tender  and  often  swollen.  The  pain,  tenderness,  and  stiff- 
ness in  the  muscles  of  the  back  from  which  many  individuals  suffer 
are  probably  due  in  a  certain  proportion  of  cases  to  some  form  of 
myositis  ;  though  in  some  other  cases,  where  the  muscles  seem  to  be 
the  seat  of  the  affection,  osteoarthritic  changes  are  undoubtedly  the 
real  cause. 

Treatment. — Rest  is  especially  necessary  in  myositis,  together  with 
counterirritation  (in  the  form  of  friction  with  liniments)  or  hot  applica- 
tions. The  bowels  should  be  kept  open  and  a  light  diet  prescribed. 
In  case  suppuration  occurs,  an  incision  should  be  made  and  the  cavity 
washed  out  and  drained.  In  rare  cases  myositis  occurs  in  a  very  acute 
form,  when  it  is  generally  progressive,  and  soon  proves  fatal. 

Tubercular  and  Syphilitic  Disease. — Muscles  may  occasion- 
ally be  the  seat  of  tubercular  or  syphilitic  deposits,  the  former  gener- 
ally associated  with  tuberculosis  in  some  adjacent  bone  or  joint,  and 
the  latter  usually  appearing  in  the  form  of  gummata.  It  has  been 
stated  that  gummata  are  very  frequently  found  in  the  sternomastoid 
muscle  of  children  born  with  inherited  syphilis  ;  but  these  swellings 
are  probably  in  a  very  large  proportion  of  cases  due  to  rupture  of  the 
muscle  during  instrumental  delivery. 

Hypertrophy  of  Muscle. — Hypertrophy  of  muscle  is  generally 
the  result  of  unusual  and  persistent  exercise.  The  limbs  of  athletes 
and  hard-worked  laborers  present  familiar  examples  of  hypertrophy 
of  voluntary  muscles,  while  the  hypertrophied  heart  and  bladder  are 
good  instances  of  the  same  condition  in  involuntary  muscles.  The 
muscular  coats  of  the  appendix  are  usually  found  to  be  much  thickened 


DISEASES   OE  MUSCLES.  JJl 

after  attacks  of  inflammation,  as  a  result  of  the  ineffectual  efforts  on 
the  part  of  that  organ  to  expel  its  contents  into  the  cecum. 

Atrophy  of  Muscle. — Just  as  muscles  may  become  hypertrophied 
by  extreme  use,  so  they  may  become  atrophied  by  long  disuse.  This 
is  a  familiar  sight  in  limbs  which  as  the  result  of  fracture,  joint-dis- 
ease, etc.,  have  been  kept  at  rest  for  a  long  time.  The  supply  of  blood 
which  has  been  furnished  to  the  muscle  is  insufficient  for  its  nourish- 
ment, and  the  muscle  wastes.  Atrophy  of  muscles  from  diminished 
blood-supply  may  also  result  from  any  cause  obstructing  the  flow  of 
blood  through  the  arteries,  as  ligature,  thrombus,  pressure  from  tumors, 
etc.  All  such  cases  are  embraced  under  the  term  simple  atrophy,  and 
are  usually  not  accompanied  by  any  form  of  degeneration.  The  mus- 
cle still  reacts  to  electricity,  though  its  size,  strength,  and  tone  are 
diminished.  Such  cases  call  for  exercise,  massage,  electricity,  etc.  In 
some  cases  of  joint  disease — even  where  there  is  nothing  more  than  a 
moderate  synovitis — there  is  a  reflex  atrophy  beyond  that  of  disuse. 
This  atrophy  is  not  attended  with  degeneration,  and  the  reflexes  are 
moderately  increased.  It  generally  affects  the  extensors  of  the  limb, 
and  is  especially  noticeable  in  the  thigh  when  the  knee  has  been  injured 
or  diseased. 

Another  form  of  atrophy,  due  generally  to  interference  with  the 
nerve-supply,  and  sometimes  the  effect  of  injury,  is  called  atrophy  zvith 
degeneration,  because  the  muscular  fibers  have  undergone  some  form 
of  degeneration  (fatty,  waxy,  granular,  or  vitreous).  The  function  of 
the  muscle  is  either  partly  or  wholly  lost,  and  the  electrical  reaction  is 
greatly  diminished  or  absent.  This  variety  of  muscular  atrophy  is  an 
especially  prominent  feature  in  progressive  muscular  atrophy,  infantile 
paralysis,  and  pseudo-hypertrophic  paralysis. 

Transplantation  of  Tendons — In  this  procedure  the  distal  tendon 
of  a  health)'  muscle  is  cut  across  or  split,  and  its  proximal  end,  or  one 
end  of  the  split  tendon,  is  stitched  firmly  into  the  tendon  of  a  paralyzed 
muscle.  This  operation  belongs  more  properly  under  Orthopedic 
Surgery  than  here,  but  a  few  words  concerning  it  may  not  be  out  of 
place. 

The  operation,  which  is  a  comparatively  new  one,  is  applicable  to 
various  paralyses  where  only  a  part  of  the  muscles  are  paralyzed,  espe- 
cially in  cases  of  infantile  paralysis  where  deformity  results  from  the 
action  of  the  healthy  muscles  whose  antagonists  are  paralyzed.  Here 
the  transplantation  of  tendons  by  counterbalancing  the  muscle-tension 
removes  not  only  the  deformity,  but  also  the  factors  which  would  lead 
to  its  recurrence. 

The  transplantation  may  in  some  cases  decrease  the  total  muscle- 
power  of  the  limb,  but  it  usually  gives  greater  usefulness  to  the  part, 
and,  beyond  this,  dispenses  with  the  need  of  retentive  apparatus. 

The  operation  has  been  widely  used  for  the  past  few  years,  and  in  a 
variety  of  forms. 

The  healthy  peroneus  longus  has  been  transplanted  into  the  tendo 
Achillis,  into  the  tendon  of  the  tibialis  posticus,  and  into  that  of  the 
tibialis  anticus.  The  extensor  proprius  pollicis  tendon  has  been  inserted 
into  the  tendon  of  the  tibialis  anticus  ;  and  the  paralyzed  rectus  femoris 
has  been  reinforced  by  the  implantation  of  the  sartorius. 


J72  INTERNATIONAL     IKXT-BOOK  OF  SURGERY. 

The  results  of  cases  thus  far  recorded  have  been  sufficiently  satis- 
factory to  justify  the  operation. 

Apart  from  the  use  of  this  operation  in  infantile  paralysis,  it  has  been 
of  definite  value  in  certain  cases  of  spastic  paralysis,  particularly  in  the 
type  known  as  Little's  disease.  Not  only  may  a  better  balance  of  mus- 
cles be  obtained  by  transplantation,  but  it  seems1  that  there  is  also  an 
unexplained  result,  inasmuch  as  after  tenotomy  and  transplantation 
there  is  a  definite  diminution  of  the  spastic  tonus  of  the  affected  muscle 
groups. 

Apart  from  this,  a  few  cases  of  wrist-drop  (musculospiral  paralysis) 
have  been  operated  on  by  tendon-shortening'  of  the  extensors  of  the 
wrist,  or  by  passing  flexor  tendons  through  the  interosseous  spaces 
and  grafting  them  to  the  paralyzed  extensors.  The  results  are  said  to 
be  good.2 

Bruns3  has  recently  advocated  transplantation  of  biceps  and  semi- 
tendinosus  tendons  into  slits  in  the  quadriceps  femoris  for  knee  con- 
tractures (in  flexion),  whether  of  paralytic  or  arthritic  origin. 

Functional  Disorders. — A  muscle  may  temporarily  lose  its 
power  as  a  result  of  overwork,  strain,  exposure  to  cold,  etc.  It  may 
or  may  not  be  subject  to  spasm  also.  Groups  of  muscles,  especially 
those  which  combine  to  carry  out  the  motions  necessary  for  a  certain 
action,  may  be  similarly  affected,  the  loss  of  power  or  the  spasm  being 
particularly  marked  when  the  attempt  is  made  to  carry  out  that  action. 
A  familiar  instance  of  this  is  known  as  "  writers'  cramp." 

Contractures  of  Muscle. — This  refers  especially  to  those  cases 
of  contracted  muscles  in  which  there  is  no  relaxation,  even  when  an 


"^ 


X 


FlG.  383. —  Method  of  lengthening  a  tendon. 


anesthetic  is  given,  and  not  to  that  class  of  reflex  contractions  accom- 
panying fractures,  inflamed  joints,  hysteria,  etc.  The  simplest  forms 
of  contracture — such,  for  instance,  as  result  from  a  part  remaining  a 
long  time  in  one  position — should  be  treated-with  passive  motion,  mas- 
sage, etc.  But  if  this  treatment  fails,  and  also  in  the  more  serious 
forms  of  contracture  where  there  is  permanent  contraction  of  the 
fibrous  elements  of  the  sheath  and  atrophy  of  the  muscular  fibers, 
the  patient  should  be  etherized,  and  an  attempt  made  to  overcome  the 
contraction  by  force.     This  will  be  successful  in  all  except  the  most 

1  Vulpius,  Centralbl.  f.    Chi).,  1899,  No.  27;  Vulpius,  Revue  de  Chir.,  1900,  p.  421; 
Kunik,  Miinchener  med.  Wochenschr.,  1901,  No.  7. 
-  W.  R.  Townsend,  Med.  News,  July  14,  iqoo. 
3  Carl  Bruns,  Centralbl./.  Chir.,  1901,  p.  159. 


DISEASES   OF   TENDONS,    TENDON-SHEATHS,   AND  FASCIAE.     773 

serious  forms,  where  tenotomy  will  be  found  necessary.  Tenotomy 
may  be  done  by  the  subcutaneous  or  the  open  method,  the  latter 
having  the  advantage  of  enabling  the  operator  to  see  what  he  is  doing, 
and  thus  avoid  damaging  important  parts.  The  tendon  may  be  cut 
transversely,  or,  what  is  often  better,  may  be  split  lengthwise  and  cut 
out  at  the  two  ends  in  opposite  directions  transversely  or  obliquely. 
The  part  should  then  be  forced  into  the  normal  position,  the  two  ex- 
tremities of  tendon  united  with  catgut  or  silk,  and  the  wound  closed 
(Fig.  383),  The  result  of  tenotomy  performed  by  either  method  is 
usually  most  satisfactory. 

Tumors  of  Muscle. — Tumors  of  muscle,  exclusive  of  those  which 
affect  the  uterus,  are  rare.  Most  varieties  of  tumor  have  been  found, 
h©wever,  sarcoma  and  its  combinations  being  perhaps  the  most  fre- 
quently met  with.  They  should  be  dealt  with  in  accordance  with  the 
general  rules  for  the  treatment  of  tumors. 

DISEASES  OF  TENDONS,  TENDON-SHEATHS,  AND  FASCIAE. 

A  tendon-sheath  is  a  closed  sac  which  partially  or  completely  sur- 
rounds a  tendon,  its  inner  layer  being  adherent  to  it.  Those  tendons 
which  possess  sheaths  are  located  chiefly  about  the  wrist,  hand,  and 
ankle. 

Inflammation  of  the  Tendon-sheaths  (Tenosynovitis). — 
Several  varieties  are  met  with:  1.  Acute  simple  tenosynovitis;  2. 
Suppurative  tenosynovitis  ;   3.  Chronic  tenosynovitis. 

Acute  simple  tenosynovitis  frequently  follows  overwork,  sprains, 
and  other  injuries.  This  form  of  the  disease  is  generally  met  with  in 
one  or  more  of  the  tendon-sheaths  near  the  wrist,  especially  in  those 
of  the  extensor  tendon  of  the  thumb  or  fingers,  and  occasionally  in 
connection  with  the  tendo  Achillis,  the  peroneal  tendons,  or  the  exten- 
sors of  the  foot.  There  is  an  elongated,  irregular  swelling  over  the 
region  of  the  affected  sheath,  from  effusion  into  the  sheath,  and  the 
part  is  tender  and  painful,  especially  on  movement.  In  the  early  stages 
a  soft  crepitus  can  usually  be  felt  when  the  tendon  moves  to  and  fro  in 
its  sheath  (tenosynovitis  crepitans). 

Treatment. — Gentle  pressure  should  be  applied  by  covering  the  part 
with  a  layer  of  contractile  collodion  or  by  sheet  wadding,  and  immo- 
bilizing the  part.  Usually,  under  this  treatment  the  inflammation  sub- 
sides in  a  few  days,  and  the  exudation  is  absorbed.  Occasionally, 
adhesions   or  chronic  inflammation  may  result. 

Suppurative  tenosynovitis  results  from  direct  infection  of  the 
sheath  with  pus-producing  organisms,  or  from  suppurative  inflamma- 
tion in  the  neighboring  structures.  This  condition  is  also  occasionally 
met  with  in  connection  with  gonorrhea  or  pyemia,  either  of  these 
diseases  appearing  primarily  in  the  sheath,  or  secondarily  to  some 
joint-affection.  Acute  suppuration  of  the  tendon-sheaths  on  the  front 
of  the  hand  and  wrist  occurs  so  frequently  in  some  forms  of  whitlow 
(the  thecal  variety)  as  to  merit  a  special  consideration. 

Thecal  whitlow  (felon)  usually  follows  some  wound  on  the  finger, 
but  occasionally  appears  without  apparent  cause.  The  suppurative 
inflammation   usually   starts   from   the  end  of  one  of  the  fingers   and 


774 


INTERNATIONAL    TEXT- BO  OK  OF  SURGERY. 


spreads  rapidly  over  the  flexor  surface  of  that  finger.  If  this  condition 
is  neglected,  sloughing  of  the  tendon  or  necrosis  of  one  or  more  of  the 
phalanges  may  result,  as  well  as  invasion  of  some  of  the  phalangeal 
or  carpal  joints,  in  which  case  the  finger  becomes  distorted  and  useless. 
Septicemia  and  pyemia  have  been  known  to  ensue.  A  special  anatom- 
ical arrangement  of  the  sheaths  of  the  flexor  tendons  makes  it  possible 
for  suppuration  in  the  sheaths  of  the  tendons  of  the  thumb  and  little 
finger  to  travel  up  to  the  palm,  and  even  under  the  annular  ligament 
into  the  forearm,  with  amazing  rapidity  (Fig.  384).  Whitlow,  therefore, 
forming  on  either  of  these  fingers  is  far  more  dangerous  than  on  either 
the  fore,  middle,  or  ring  fingers. 

Symptoms. — Acute  suppuration   in  tendon-sheaths  extends  rapidly 
throughout  the  entire  length  of  the  sheath,  and  is  accompanied  by  the 


FlG.  384. — Diagram  showing  arrangement  of 
flexor  sheaths  on  the  front  of  the  hand. 


FlG.  385. — Diagram  showing  proper 
incisions  into  the  palm. 


usual  symptoms  characteristic  of  acute  suppuration.  In  whitlow  the 
pain  is  extreme  and  of  the  throbbing  kind,  increased  almost  beyond 
endurance  when  the  hand  hangs  down.  The  finger  appears  red,  shiny, 
swollen,  and  is  exquisitely  tender.  Lymphangitis  and  brawny  infiltra- 
tion of  the  tissues  of  the  forearm  may  follow  as  the  inflammation 
travels  upward.  In  pyemia  suppuration  appears  insidiously  in  one  or 
more  sheaths  without  causing  special  symptoms  except  swelling. 

Treatment. — Before  the  presence  of  pus  is  evident,  hot  creolin  baths 
and  creolin  poultices  may  be  employed  with  advantage  ;  but  when  sup- 
puration has  taken  place,  a  free  incision  should  be  made  at  once,  and 
the  entire  track  of  the  abscess  cleaned,  washed  out,  and  scrubbed  with 
hydrogen  peroxid.  If  immediate  incision  is  made,  it  prevents  the 
spreading  of  the  suppurative  process  to  other  structures,  and  probably 
saves  the  tendon.  Free  drainage  should  always  be  used.  In  case  the 
pus  has  reached  the  palm,  an  incision  should  be  made  so  as  to  avoid 


DISEASES   OF   TENDONS,    TENDON-SHEATHS,    AND   FASCIsE.     775 


the  vessels  (Fig.  385).  The  palmar  incision  of  W.  A.  Brooks  (see  page 
J^)  has  much  to  recommend  it. 

Chronic  tenosynovitis  may  be  chronic  from  the  beginning,  or  may 
result  from  repeated  acute  and  subacute  attacks,  especially  in  indi- 
viduals who  have  a  tendency  to  tuberculosis.  There  are  several  vari- 
eties of  the  disease,  though  modern  pathol- 
ogy considers  a  very  large  proportion,  if  not 
all,  of  them  to  be  tuberculous.  The  sheath 
is  distended  with  fluid,  which  may  be  serous, 
somewhat  turbid,  or  gelatinous,  and  may 
contain  numerous  small  bodies,  the  so-called 
"  melon-seed  bodies,"  which  are  made  up  of 
concentric  layers  of  fibrinous  material,  and 
which  float  freely  within  the  sac.  The  lining 
of  the  sac  may  be  smooth  or  roughened  with 
fibrinous  deposit.  Instill  another  form  of  the 
disease,  the  so-called  "fungous"  variety,  the 
sac  is  filled  with  granulations,  which  may 
burst  beyond  the  limits  of' the  distended  sac 
and  invade  the  neighboring  structures.  The 
sheaths  most  frequently  affected  are  those  on 
the  front  of  the  wrist  (the  so-called  great 
carpal  bursa),  the  back  of  the  wrist,  the  dor- 
sum of  the  foot,  and  behind  the  external 
malleolus  (the  sheaths  of  the  peroneal  ten- 
dons). 

Signs. — The  disease  appears  as  a  chronic 
elongated  swelling  over  the  tendon.     There 

is  little  or  no  pain  or  tenderness,  and  the  skin  is  usually  not  reddened. 
The  swelling  is  soft  and  elastic,  and  gives  an  indistinct  feeling  of  fluc- 
tuation. When  the  great  palmar  bursa  is  affected,  there  is  a  swelling 
in  the  palm  and  also  one  above  the  wrist,  the  two  being  separated  by 
a  constriction  at  the  level  of  the  annular  ligament  (Fig.  386).  As 
the  fluid  is  pressed  from  one  swelling  to  the  other,  a  peculiar  soft 
crepitation  may  occasionally  be  felt,  which  is  caused  by  the  melon- 
seed  bodies  passing  under  the  annular  ligament.  Some  of  the  sheaths 
of  the  other  flexor  tendons  of  hand  or  fingers  may  be  affected  at  the 
same  time.  In  the  fungous  variety  of  the  disease  the  skin  may  become 
involved  and  break  down,  resulting  in  ulcerations  and  sinuses. 

Treatment. — Although  most  cases  of  chronic  tenosynovitis  are 
probably  tubercular,  and  will  resist  all  ordinary  forms  of  treatment, 
it  may  be  well  in  simple  cases  to  try  the  effect  of  immobilization,  firm 
compression,  counterirritation,  etc.,  combined  with  tonics  and  good 
hygienic  surroundings.  If  these  fail  after  faithful  trial,  the  entire  sac 
with  all  its  contents  should  be  carefully  removed  by  dissection,  together 
with  any  tissue  outside  the  sac  which  appears  to  be  affected.  The  use 
of  an  Esmarch  tourniquet  will  greatly  simplify  the  operation.  The 
functional  result,  especially  when  the  disease  is  primary,  is  usually 
very  satisfactory,  and  in  most  cases  there  is  no  recurrence  of  the 
disease. 

Ganglion. — A  ganglion,  or  "  weeping-sinew,"  as  it  is  sometimes 


Fig.  386. — Chronic  teno- 
synovitis of  the  flexor  tendon- 
siieaths  on  the  front  of  the 
wrist. 


776  INTERNATIONAL    TEXT- BOOK  OE  SURGERY. 

called,  is  a  round,  firm  swelling  in  connection  with  a  tendon-sheath. 
It  has  thin  walls  and  a  synovial  lining,  and  contains  a  thick  gelatinous 
fluid.  Its  most  common  situation  is  on  the  dorsal  aspect  of  the  wrist, 
where  it  lies  in  intimate  connection  with  the  sheath  of  one  of  the 
extensor  tendons  of  the  fingers  (Fig.  387).  It  is  also  occasionally  seen 
in  connection  with  the  flexor  tendons  on  the  anterior  surface  of  the 
wrist,  or  even  in  the  palm.     Its  mode  of  formation  is  not  entirely  clear, 


ion  on  the  back  of  the  wrist. 


though  it  is  probably  developed  from  a  protrusion  of  a  pouch  of  syno- 
vial membrane  of  the  tendon-sheath  through  some  aperture  in  its 
fibrous  envelope.  This  pouch  becomes  larger  and  larger,  possibly  as 
the  result  of  excessive  secretion  of  synovial  fluid  from  overuse  of  the 
tendon,  sprain,  etc.  Apparently  in  most  cases  the  neck  of  the  sac 
becomes  more  and  more  constricted,  and  finally  its  lumen  is  obliterated, 
so  that  all  connection  with  the  cavity  of  the  tendon-sheath  is  shut  off. 

Treatment. — A  ganglion  may  be  treated  by  subcutaneous  rupture, 
subcutaneous  incision,  or  by  excision  of  the  sac  and  its  contents.  It  is 
usual,  when  the  situation  of  the  ganglion  will  allow  it,  to  try  these 
various  expedients  in  the  order  here  given.  Thus,  a  ganglion  on  the 
back  of  the  wrist  is  made  prominent  by  strongly  flexing  the  wrist, 
when  the  sac  is  ruptured  by  firm  pressure  with  both  thumbs,  or  by  a 
quick  blow  with  a  heavy  book.  It  is  well  after  this  to  keep  the  hand 
and  forearm  confined  to  a  splint  for  a  few  days,  with  firm  pressure 
applied  over  the  seat  of  the  ganglion.  Even  after  successful  rupture, 
however,  the  sac  may  refill,  and  a  different  kind  of  treatment  should  be 
used.  The  skin  may  be  pulled  to  one  side  over  the  swelling,  and  a 
tenotome  passed  quickly  into  the  cavity  of  the  sac.  The  inner  lining 
of  the  sac  is  then  scarified  by  the  tip  of  the  tenotome,  or  the  entire  sac- 
wall  divided  subcutaneously,  after  which  the  contents  of  the  sac  are 
squeezed  out  and  the  skin  allowed  to  slide  back  to  its  proper  place, 
thus  leaving  a  long  oblique  opening  into  the  sac,  which  diminishes  the 
danger  of  infection.  The  last  resort  in  these  cases  is  excision  of  the 
entire  ganglion — an  operation  which,  properly  done,  is  invariably  suc- 
cessful in  preventing  a  return  of  the  condition. 

Dupuytren's  Contraction  of  the  Palmar  Fascia. — This  is  a  con- 
dition in  the  palm  of  the  hand,  which,  from  its  appearance  and  from  the 
fact  that  one  or  more  fingers  are  permanently  flexed,  formerly  gave  rise 
to  the  impression  that  it  was  due  to  a  contraction  of  the  flexor  muscles 
or  tendons.     Baron  Dupuytren  was  the  first  to  point  out  that  the  con- 


DISEASES   OF   TENDONS,    TENDON-SHEATHS,    AND   FASCIAE,     yjj 


Fig.  388. — Dupuytren's  con- 
traction of  the  palmar  fascia 
(after  Reeves). 


clition  is  entirely  due  to  a  contraction  of  the  palmar  fascia,  and  since  that 
time  the  disease  has  always  borne  his  name.  The  fascia  in  the  palm 
opposite  one  or  more  of  the  fingers  (the  dis- 
ease usually  begins  opposite  the  ring  or  little 
finger,  and  may  spread  to  the  others)  is  thick- 
ened and  projects  from  the  palm  in  the  form 
of  one  or  more  rounded  cords  or  bands  to 
which  the  skin  is  quite  firmly  adherent,  being 
disposed  over  it  in  many  transverse  folds  and 
depressions.  One  finger  only  may  be  flexed, 
or  several  in  different  degrees.  The  flexion 
may  be  slight,  or  it  may  be  so  extreme  that 
one  or  more  fingers  are  brought  into  the  palm 
(Fig.  388). 

The  condition  is  more  frequent  in  men 
than  in  women,  and  is  oftener  found  in  the 
right  than  in  the  left  hand,  though  occasion- 
ally in  both.  Though  this  contraction  prob- 
ably results  from  some  form  of  chronic  in- 
flammation, its  exact  cause  is  not  at  all  clear. 
In  certain  cases  it  seems  to  have  been  traced 
to  some  slight  or  repeated  injury  or  to  the 
continuous  use  of  certain  tools.  It  has  also 
been  attributed  to  rheumatism,  though  prob- 
ably without  sufficient  reason. 

Treatment. — Forcible  extension  does  no  good  whatever.  The 
deformity  returns  just  as  soon  as  the  extension  is  discontinued.  Opera- 
tion is  the  only  means  by  which  a  cure,  or  even  improvement,  can  be 
expected ;  and  even  with  operation  a  certain  amount  of  recontraction 
may  occur,  especially  if  the  wound  fails  to  heal  by  primary  union.  The 
contracted  bands  may  be  divided  by  multiple  subcutaneous  incisions, 
or,  what  seems  better,  they  may  be  dissected  out  freely  through  an  open 
incision  in  the  palm.  A  V-shaped  incision,  with  apex  toward  the  fin- 
gers, is  strongly  advised,  as  giving  the  operator,  on  lifting  the  flap,  more 
room  to  dissect  out  all  the  contracted  bands,  and,  by  placing  the  skin- 
incision  away  from  the  tendon,  to  minimize  subsequent  recontraction 
after  the  wound  has  healed.  The  finger  should  be  kept  extended  for 
two  or  three  weeks  after  the  operation,  and  later,  massage  should  be 
used.  Lotheissen  has  recently  recommended  a  curved  incision  running 
along  the  ulnar  side  of  the  hand  and  above  the  hypothenar  eminence. 
This,  too,  gives  a  flap  with  the  skin  incision  out  of  the  way  of  the 
tendon. 

A  slight  degree  of  Dupuytren's  contraction  which  shows  no  ten- 
dency to  increase  does  not,  as  a  rule,  call  for  any  operation  whatever. 

Hammer-toe. — This  is  a  common  deformity  in  which  the  tendons 
and  muscles  take  sufficient  part  to  justify  its  consideration  here.  The 
deformity  is  most  frequent  in  the  second  toe,  though  it  may  exist  in  any 
of  the  smaller  toes.  Both  feet  are  often  affected.  The  first  phalanx  is 
extended,  the  second  strongly  and  rigidly  flexed,  and  the  terminal  pha- 
lanx either  in  a  straight  line  continuous  with  the  second,  or  extended 
upon  it  (Fig.  389).     A  callus  forms  over  the  head  of  the  first  phalanx, 


778 


INTERNATIONAL    TEXT  BOON  OF  SURGERY. 


and  another  on  the  tip  of  the  toe,  these  representing  the  places  sub- 
jected to  the  greatest  friction  when  the  foot  is  moved  within  the  shoe. 
As  might  be  expected,  this  condition  makes  walking  difficult  and  pain- 
ful. Though  inheritance,  rheumatism,  and  gout  have  often  been  consid- 
ered responsible  for  this  deformity,  it  is  probable  that  the  most  frequent 
if  not  the  sole  cause  is  to  be  found  in  the  wearing  of  shoes  which  are 
either  too  short  (thus  pressing  the  toes  back)  or  too  narrow  at  the  tip 
(thus  squeezing  the  toes  together),  or  both.  Assuming  that  hammer- 
toe is,  as  the  writer  believes  it  to  be,  invariably  caused  by  defective  foot- 
wear, its  development  may  be  explained  as  follows :  An  unusually  long 
second  toe  is  forced  backward  by  a  short  shoe,  and  at  the  same  time, 
on  account  of  lateral  crowding,  is  overridden  by  the  great  toe  on  one 
side  and  the  third  toe  on  the  other.  The  tip  of  the  second  toe  is  never 
again  able  to  return  to  its  proper  level,  but  is  forced  more  and  more 
backward  by  the  encroachment  of  the  two  neighboring  toes.  During 
this  process  the  first  phalangeal  joint  becomes  strongly  flexed  and  pro- 


FlG.  389. — Hammer-toe. 

jects  above  the  level  of  the  first  and  third  toes,  which  come  closer 
and  closer  together  above  its  tip.  This  deformity  is  kept  up  by  the 
persistence  of  the  conditions  which  originally  caused  it — that  is,  the 
continuing  to  use  improperly  shaped  shoes.  All  the  structures  (includ- 
ing muscles,  tendons,  and  especially  ligaments)  which  are  made  slack 
by  this  position  contract,  the  ends  of  the  bones  accommodate  them- 
selves to  the  new  condition,  and  rigidity  results. 

Treatment. — In  cases  where  the  deformity  has  not  fully  developed, 
and  especially  if  the  subject  is  youthful,  an  attempt  may  be  made  to 
correct,  or  at  least  lessen,  the  deformity  by  passive  motion,  by  the 
wearing  of  loose  but  well-fitting  shoes  which  allow  full  play  of  the 
toes,  or  by  the  continued  use  of  some  mechanical  device.  Subcutaneous 
division  of  the  contracted  ligaments  about  the  first  phalangeal  joint 
has  not  proved  to  be  of  any  great  value,  and  tenotomy  of  flexor  tendons 
with  forcible  extension  by  which  these  bands  are  ruptured  has  met 
with  only  partial  success.  Resection  of  the  head  of  the  first  phalanx 
or  of  the  first  phalangeal  joint  is  the  operation  which  is  now  generally 
recommended.     Karewski   speaks  well  of  tenotomy  with  arthrodesis. 


DISEASES   OF   TENDONS,    TENDON-SHEATHS,    AND   FASCLE.     Jjg 


Although  the  result  is  usually  an  improvement,  it  is  far  from  being 
ideal.  The  first  phalanx  is  apt  to  remain  hyperextended,  and  there  is 
appreciable  broadening  of  the  toe  at  the  point  of  resection,  as  a  result 
of  retraction  of  the  entire  toe.  For  this  reason  the  toe  lies  above  the 
gap  intended  for  it,  and  not  in  it.  Fig.  390  is  taken  from  a  photograph 
of  a  case  of  hammer-toe  about  a  month  after  the  head  of  the  first 
phalanx  had  been  excised. 


FlG.  390. — Result  of  excision  of  the  head  of 
the  first  phalanx  for  hammer-toe. 


FlG.  391. — Result  of  amputation  in  ham- 
mer-toe. The  toes  have  come  together 
diminishing  the  gap. 


Amputation  of  the  Toe. — This  is  the  best  procedure  for  the  most 
intractable  cases  (Fig.  391).  The  loss  of  the  second  toe  does  not  seri- 
ously weaken  the  foot  or  interfere  with  walking.  If  there  should  be 
later  a  tendency  to  hallux  valgus,  as  some  surgeons  claim,  great  care 
should  be  used  that  the  shape  of  the  shoes  worn  after  the  operation  be 
such  as  to  give  plenty  of  room  for  the  toes  in  all  directions. 

Snap-finger  (Trigger-finger). — This  is  a  very  rare  as  well  as  a 
very  peculiar  condition.1  Owing  to  some  obstacle  to  the  free  play  of 
the  tendon  (usually  the  flexor)  o*f  one  of  the  fingers,  there  is  sudden 
interruption  of  flexion  or  extension,  or  both,  after  which  time  the  mo- 
tion is  resumed  with  a  jerk.  The  condition  is  probably  due  to  the 
fact  that  the  tendon  at  one  part  has  became  thicker  than  normal,  and 
that  when  this  affected  portion  comes  to  the  narrowest  part  of  the  canal, 
it  is  there  arrested  temporarily  until  by  force  it  is  pulled  through,  and 
the  finger,  with  a  snap,  is  flexed  or  extended  as  the  case  may  be.  Occa- 
sionally a  small  nodule  may  be  felt  on  the  palm,  which  corresponds 
to  the  thickened  portion  of  the  tendon  above  described.     Exactly  what 

1  A  relatively  large  number  of  cases  are  reported  as  having  been  met  with  among  the 
recruits  of  the  German  army.  It  is  supposed  that  the  trouble  is  due  to  handling  weapons 
with  hands  unused  to  hard  work. 


780  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

this  enlargement  of  the  tendon  is,  and  whether  it  is  due  to  a  general 
thickening  of  the  tendon  or  to  an  outgrowth  from  it,  or  to  the  synovial 
fringes  within  the  canal,  is  not  known.  Schloffer1  examined  one  of 
these  thickenings  pathologically  after  removal,  and  found  only  a  some- 
what infiltrated  normal  tendon.  Sudeck  2  found  not  a  thickening,  but  a 
localized  atrophy  of  the  profundus  tendon  in  its  sheath.  This  case 
showed  free  flexion  but  a  snap  in  extension. 

As  for  the  treatment,  passive  motion  may  be  persistently  tried,  and 
if  this  fails  to  give  relief,  an  incision  should  be  made,  opening  the 
sheath  and  exposing  the  tendon,  after  which  any  obstacle  to  the  free 
play  of  the  tendon  may  be  removed. 

INJURIES  AND  DISEASES  OF  THE  BURSAE. 

There  are  two  kinds  of  bursae  in  the  body — the  mucous  and  the 
synovial.  Mucous  bursce  are  loose  irregular  sacs  in  the  subcutaneous 
tissues,  containing  a  clear  viscid  fluid.  They  are  found  over  bony  pro- 
jections, such  as  the  olecranon,  patella,  tip  of  the  os  calcis,  malleoli, 
etc.  Bursae  similar  to  these  may  develop  of  themselves  just  under  the 
skin  from  unusual  friction,  as  on  the  dorsum  of  the  foot  in  cases  of 
extreme  talipes  varus,  on  a  projecting  spinal  hump  resulting  from  Pott's 
disease,  under  corns,  etc.  Synovial  burses  are  placed  more  deeply  in  the 
body  than  the  mucous  variety.  They  lie  between  tendons  or  between 
tendons  and  bone.  When  they  occupy  a  position  near  a  joint,  they  are 
very  apt  to  communicate  with  the  cavity  of  that  joint,  as  is  generally  the 
case  in  the  bursa  under  the  tendon  of"  the  subscapularis,  also  in  that 
between  the  iliacus  tendon  and  the  capsule  of  the  hip-joint,  and  also  in 
that  between  the  tendon  of  the  semimembranosus  and  the  inner  head 
of  the  gastrocnemius.  All  varieties  of  bursae  are  subject  to  injury, 
and  are  especially  liable  to  inflammation  and  its  results. 

Injuries  of  Bursae. — Bursas  are  subject  to  all  forms  of  injury. 
The  proper  treatment  of  an  injured  bursa  is  rest  and  cold  applications. 
Occasionally  bursae  are  wounded,  especially  in  operations.  They  usually 
heal  readily  unless  infected.  If  infected,  they  are  sure  to  suppurate. 
If  there  is  a  penetrating  wound  of  a  bursa,  especially  if  there  is  reason 
to  believe  it  an  infected  one,  the  entire  cavity  should  be  laid  open  and 
thoroughly  cleaned  out. 

Diseases  of  Bursae. — Inflammation  of  bursae  (bursitis),  both  acute 
and  chronic,  is  extremely  common.  A  knowledge  of  the  anatomical 
position  of  the  various  bursae  is  often  of  great  assistance  in  making 
the  diagnosis. 

Acuite  bursitis  is  generally  due  to  injury,  excessive  muscular  action, 
or  infection.  It  may  also  be  caused  by  extension  of  inflammation  from 
a  neighboring  joint.  The  lining  of  the  sac  is  congested,  and  fluid  is 
secreted,  often  with  great  rapidity.  Occasionally  there  is  some  blood 
mixed  with  the  fluid.  This  condition  may  result  in  resolution  or 
suppuration. 

Signs. — The  part  is  painful,  reddened,  swollen,  and  very  tender.  If 
suppuration  takes  place,  there  may  be  a  chill,  accompanied  by  sudden 
rise  of  temperature  and  marked  increase  in  all  the  local  signs.     Fluc- 

1  IVien.  klin.   VVochenschr.,  1901,  No.  I.  2  Beitr.  z.  klin.  C/iir.,  xxvi.,  H.  2. 


IXJURIES  AND  DISEASES   OF  THE  BURSAS.  78 1 

tuation  will  be  evident  sooner  or  later.  If  the  abscess  is  not  opened, 
it  will  break  of  itself  and  discharge,  possibly  leaving  a  long  sinus. 

Treatment. — When  a  bursa  is  simply  inflamed,  an  attempt  should  be 
made  to  cause  resolution  by  immobilizing  the  part  with  splint  or  band- 
age and  placing  it  in  such  position  as  to  relax  the  muscles.  Cold  (in 
the  form  of  ice-bags)  or  hot  moist  applications  should  be  employed,  and 
in  case  an  undue  quantity  of  fluid  is  present,  the  bursa  should,  if  ac- 
cessible, be  aspirated.  When  pus  is  present,  the  cavity  should  be  freely 
laid  open,  scraped,  cleaned,  and  drained. 

Chronic  bursitis  may  begin  as  such  or  may  be  the  result  of  several 
acute  attacks.  Constant  friction  is  also  a  common  cause.  Several  dis- 
tinct conditions  may  result  from  chronic  bursitis  :  (1)  The  bursa  may  be 
simply  distended  and  filled  with  a  thin  clear  fluid ;  or  (2)  the  wall  may 
be  considerably  thickened,  and  lined  with  flabby  granulations  or  with 
fibrinous  deposits,  some  of  which  deposits  may  be  free  within  the  cav- 
ity of  the  bursa;  or  (3)  the  wall  may  be  so  thick  as  almost  to  obliterate 
the  central  cavity.  Suppuration  is  not  uncommon,  and  in  very  old 
cases  calcification  occasionally  takes  place.  There  is  good  reason  to 
believe  that  many  of  these  chronically  inflamed  bursae  are  tuberculous. 

Signs. — The  most  prominent,  and  often  the  only,  sign  of  a  chron- 
ically inflamed  bursa  is  a  marked  bulging  under  the  skin  to  be  seen  or 
felt  when  the  bursa  is  near  the  surface ;  this  is  due  to  distention  of  the 
sac.  Some  stiffness  may  be  present,  but  actual  pain  is  either  very 
slight  or  absent.  If  the  bursa  is  a  superficial  one,  fluctuation  can  gen- 
erally be  made  out.  This  is  not  so  evident,  however,  when  the  walls 
become  thicker ;  in  fact,  in  some  cases  they  are  so  thick  and  dense  as 
to  give  the  impression  that  the  swelling  is  solid.  If  suppuration  has 
occurred,  there  is  some  pain  with  tenderness,  and  the  skin  over  the 
bursa  is  reddened. 

Treatment. — In  cases  where  suppuration  has  not  occurred,  aspira- 
tion followed  by  firm  compression  and  immobilization  of  the  part  is 
sufficient  to  effect  a  cure ;  but  the  bursa  is  liable  to  become  again  dis- 
tended with  fluid,  in  which  case,  if  it  is  accessible,  it  may  be  freely  laid 
open  and  curetted  and  the  skin  united  over  it.  Complete  excision  is, 
however,  the  best  treatment  for  all  except  the  simplest  forms  of  chron- 
ically inflamed  bursae.  The  bursas  which  are  most  commonly  affected, 
and  are  therefore  brought  most  frequently  to  the  attention  of  the  sur- 
geon, are  those  about  the  knee. 

The  prepatellar  bursa  is  perhaps  more  commonly  affected  than  all  the 
other  bursae  in  the  body  together.  On  account  of  its  exposed  position 
on  the  tip  of  the  knee,  it  is  subject  to  frequent  injuries  and  much 
friction,  and  is  liable  to  all  the  forms  of  inflammation.  It  is  so  com- 
monly enlarged  in  domestics  as  to  give  rise  to  the  name  of  "  house- 
maid's knee  "  (Fig.  392).     Occasionally  both  knees  are  affected. 

The  bursa  ewer  the  tubercle  of  the  tibia  is  occasionally  chronically 
enlarged  on  one  or  both  knees.  The  situation  of  the  swelling  over  the 
tubercle  of  the  tibia  (Fig.  393)  should  at  once  distinguish  it  from  the 
foregoing. 

The  bursa  under  the  ligamentum  patella  is  occasionally  enlarged  and 
tender — a  condition  which  may  resemble  joint-disease.  As  Lovett  has 
pointed  out,   however,  there  is  in   inflammation   of  this   bursa  undue 


782 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


prominence  on  each  side  of  the  ligamentum  patellae,  especially  when 
the  knee  is  semiflexed,  and  at  the  same  time  the  normal  depressions 
at  both  sides  of  the  patella  remain  unaffected. 

The  bursa  under  the  quadriceps  extensor  tendon  usually  communi- 
cates with  the  joint  and  partakes  in  its  inflammations,  but  it  may 
enlarge  on  its  own  account,  forming  a  projecting  mass  about  3  or  4 
fingers'  breadth  above  the  patella. 

The  bursa  between  the  tendon  of  the  semimembranosus  and  the  inner 
head  of  the  gastrocnemius  is  quite  frequently  enlarged,  forming  a  glob- 


FlG.  392. — Enlarged  prepatellar  bursa. 


FlG.  393. — Enlargement  of  the  bursa  over 
tubercle  of  tibia. 


FlG.  394. — Enlarged  bursa  between  the  ten- 
don of  the  semimembranosus  and  the  inner 
head  of  the  gastrocnemius. 


ular  fluctuating  swelling  at  the  inner  side  of  the  popliteal  space,  espe- 
cially prominent  and  tense  during  extension  of  the  knee  (Fig.  394). 

Other  bursae  in  the  body  occasionally  affected  are  (1)  in  the  upper 
extremity,  the  subdeltoid  bursa  (when  it  is  liable  to  be  mistaken  for 
disease  of  the  shoulder-joint) ;  the  bursa  over  the  tip  of  the  olecranon 
(miners'  elbow) ;  and  that  betzveen  the  tendon  of  the  triceps  and  olecra- 
non (the  swelling  is  on  both  sides  of  the  tendon).;   (2)  in  the  lower 


INJURIES  AND   DISEASES    OF   THE   BURSsE. 


783 


extremity,  the  subgluteal  bursa  (between  the  gluteal  tendons  and  the 
great  trochanter) ;  the  bursa  over  the  tuber  ischii  ("  coachman's  bursa  " 
or  "  weavers'  bottom  ") ;  the  bursa  between  tJie  iliacus  tendon  and  the 
cap  side  of  the  hip-joint ;  the  bursa  over  the  os  calcis  and  that  between 
the  tendo  Achil/is  and  the  os  caleis ;  the  bursa  over  the  outer  malleolus 
(tailors'  bursa) ;  and,  lastly,  the  bursa  over  the  head  of  the  metatarsal 
bone  of  the  great  toe  (the  enlargement  of  which  is  called  "  bunion  "). 

Bunion. — Though  the  term  usually  refers  to  an  enlarged  bursa  at 
the  site  above  mentioned,  it  is  also  applicable  to  any  enlarged  bursa 
over  any  bony  prominence  about  the  toes. 
When  it  exists  over  the  head  of  the  metatarsal 
bone  of  the  first  toe,  it  is  almost  always  asso- 
ciated with  an  undue  prominence  of  that  part 
of  the  bone,  caused  by  a  deviation  of  the  great 
toe  outward  (hallux  valgus)  (Fig.  395)-  This 
deviation  in  the  direction  of  the  toe,  and  the 
development  of  a  bunion  on  the  prominent 
head  of  the  metatarsal  bone,  are  generally,  if 
not  always,  due  to  the  same  cause — viz.,  the 
continuous  wearing  of  boots  of  such  faulty 
shape  that  all  the  toes  are  crowded  together 
and  the  bony  prominences  are  subjected  to 
constant  friction. 

A  bunion  is  usually  associated  with  more  or 
less  pain  and  disability.  It  is  especially  liable 
to  inflammation  whenever  the  conditions  which 
originally  caused  the  bunion  are  allowed  to 
continue.  Occasionally  suppuration  occurs, 
when  the  pain  and  tenderness  become  extreme 
and    the    disability   complete.      If   the   case  is 

neglected,  pus  may  break  through  the  skin  (leaving  a  sinus),  or  into  the 
cellular  tissue  (causing  cellulitis  in  the  entire  neighborhood),  or  into  the 
joint  (resulting  in  destructive  arthritis). 

The  most  important  step  in  the  treatment  of  bunions  is  the  removal 
of  pressure,  and  this  may  be  accomplished  in  the  early  stages  by  the 
use  of  properly  shaped  boots  or  shoes,  which  should  have  abundant 
space  in  the  tip  to  receive  all  the  toes  without  crowding.  If  inflamma- 
tion occurs,  an  ice-bag  may  be  applied,  or,  what  is  often  better,  hot 
creolin  foot-baths  may  be  frequently  used,  the  foot  being  elevated 
between-times  and  enveloped  in  hot  moist  dressings.  If  suppuration 
takes  place,  the  pus-cavity  should  be  laid  open  freely,  scraped,  washed 
with  hydrogen  peroxid,  and  drained.  If  the  joint  is  involved,  arthrec- 
tomy  or  even  amputation  of  the  toe  may  be  required. 


FIG.  395. — Bunion  with  hal- 
lux valgus. 


CHAPTER    XXIV. 

CRANIAL   SURGERY. 

Anatomical  Peculiarities  of  the  Scalp. — When  considering 
diseases  and  injuries  of  the  scalp  it  will  be  proper  to  remember  certain 
anatomical  peculiarities.  The  hairy  skin  is  intimately  united  with  the 
tendon  of  the  occipitofrontalis  muscle,  and  together  they  move  freely 
over  the  bones  of  the  head,  loose  connective  tissue  being  interposed 
between  the  two.  Blood  or  pus  will  tend,  therefore,  to  be  diffused  in 
contact  with  the  bones,  raising  the  scalp.  In  exceptional  cases  this 
extends  over  the  whole  vault  of  the  cranium.  There  is  free  communi- 
cation between  the  veins  outside  the  skull  in  the  scalp  and  the  sinuses 
inside  the  skull  adjacent  to  the  brain.  Hence  inflammation  of  the  veins 
without  extends  easily  to  the  veins  within.  The  same  may  be  said  of 
the  lymphatic  channels.  The  presence  of  hair  on  the  scalp  in  greater 
or  less  quantity  tends  to  retain  in  connection  with  the  skin  much  dirt, 
and  in  injuries  of  the  scalp  the  most  important  thing  to  remember  is 
that  the  wound  becomes  infected  with  great  rapidity,  and  the  usual 
results  follow.  Inflammation  occurring  in  the  scalp  will  extend  and 
give  rise  to  a  great  swelling.  The  blood-tumor  so  often  seen  after 
injury  will  be  under  the  scalp  adjacent  to  the  bone,  and  may  be  so 
excessive  as  to  raise  the  entire  scalp  into  a  large  puffy  tumor. 

INJURIES  AND  DISEASES  OF  THE  SCALP. 

Injuries  of  the  Scalp. — Contused,  lacerated,  or  incised  wounds  of 
the  scalp  are  met  with,  some  penetrating  to  the  skull,  and  others  not. 
It  is  usual  in  surgical  treatises  to  consider  these  various  forms  of  scalp- 
injury,  yet  I  think  that,  apart  from  the  recognition  of  the  actual  amount 
of  injury  existing,  as  one  method  of  treatment  is  applicable  for  all  of 
them,  they  may  be  spoken  of  together.  There  is  no  class  of  injuries 
which  in  the  past  has  given  more  trouble  or  at  the  present  time  is  more 
capable  of  being  rendered  innocuous  than  the  class  under  discussion. 
The  treatment  is  as  follows  :  The  scalp  is  to  be  shaved  over  and  adja- 
cent to  the  seat  of  injury,  cleansed  by  free  scrubbing  with  a  nail-brush, 
preferably  sterilized,  using  much  hot  water  and  alkaline  soap,  then  using 
alcohol.  This  cleansing  is  to  be  extended  to  torn  and  bleeding  sur- 
faces. If  the  wounds  are  lacerated,  as  in  railway  injuries  and  machinery 
accidents,  and  dirt  and  grease  ground  into  the  tissues,  by  means  of  the 
nail-brush  with  soap,  ether,  and  alcohol  the  tissues  are  to  be  rendered 
clean.  Ragged  and  very  much  lacerated  edges  are  to  be  trimmed  off. 
Wounds  extending  under  the  scalp  are  to  be  slit  up  and  scrubbed. 
Briefly,  the  entire  wounded  surface  is  to  be  treated  in  such  a  way  that 
there  are  no  undermined  tracks  or  hidden  dirt.  Then  the  edges  of  the 
wounds  are  to  be  brought  together  lightly,  not  tightly,  by  silkworm-gut 

784 


INJURIES  AXD   DISEASES   OF   THE   SCALP.  785 

sutures,  a  voluminous  dressing  of  gauze  and  cotton  is  to  be  applied, 
and  a  bandage  to  hold  everything  snugly  in  place.  Outside  of  all  a 
plaster-of-Paris  bandage  or  crinoline  bandage  will  be  useful.  Such  a 
dressing,  if  applied  over  properly  cleansed  surfaces,  can  remain  without 
disturbance  until  healing  is  complete.  It  is  better  not  to  bring  together 
the  scalp-edges  closely,  for  nothing  is  more  certain  to  induce  suppura- 
tion than  the  tension  from  tight  suturing.  The  bleeding  which  is  usual 
after  scalp-injuries  will  be  arrested  by  ligature  or  by  sutures  passed 
deeply  under  a  spurting  vessel  by  means  of  a  curved  needle.  Thorough 
hemostasis  is  necessary  before  the  wound  is  closed. 

An  incised  wound  of  the  scalp  does  not  require  a  sharp  instrument  for  its  production. 
The  vault  of  the  cranium  on  one  side  and  a  flat  hard  body  on  the  other  will  press  the  scalp 
and  so  give  rise  to  an  incised  wound.  A  fall  on  the  pavement  is  an  excellent  example  of  a 
straight  clean  wound  produced  in  this  way.  Where  the  injury  is  over  a  large  surface  and 
rather  slanting,  not  directly  toward  the  skull,  a  triangular  flap  of  scalp  is  torn.  Occasionally, 
after  the  healing  of  scalp-wounds  neuralgia  of  a  more  or  less  pronounced  character  results. 
This  is  due  to  the  entanglement  of  a  nerve  in  the  cicatrix.  If  the  pain  does  not  pass  away 
after  the  cicatrix  is  well  formed,  it  may  be  necessary  to  dissect  the  nerve  out  of  the  scar,  or 
cut  it  across  proximal  to  the  point  where  compressed,  so  as  to  give  relief. 

Cellulitis  of  the  Scalp. — Cellulitis  of  the  scalp  occurs  in  both 
chronic  and  acute  forms.  As  an  acute  infection  it  follows  an  injury, 
and  the  usual  symptoms  will  be  present.  It  extends  rapidly,  with 
marked  constitutional  symptoms,  and  the  resulting  effusion  rapidly 
becomes  purulent.  As  the  blood-  and  nerve-supply  of  the  scalp  comes 
from  the  periphery,  sloughing  of  the  scalp  and  gangrene  are  not  usual ; 
but  repair  is  slow,  and  unless  the  pus  is  evacuated  by  incisions  there  is 
danger  of  purulent  infection  through  the  veins  which  communicate 
with  the  interior  of  the  skull  and  the  diploe ;  then  the  prognosis  is 
extremely  grave.  Circumscribed  cellular  inflammation  is  often  seen, 
the  result  of  traumatism  with  consequent  infection.  The  occurrence 
of  numerous  abscesses  of  the  scalp  indicates  a  diminished  resisting 
power  of  the  tissues ;  it  exists  with  constitutional  weakness  such  as  is 
associated  with  tuberculosis  in  children,  etc. 

Chronic  cellulitis  of  the  scalp  is  often  syphilitic,  and  there  is  a 
decided  tendency  for  the  inflammatory  process  to  occur  in  the  middle 
line. 

Erysipelas  of  the  Scalp. — This  is  more  apt  to  be  seen  as  an  extension  from  adja- 
cent parts,  notably  the  face,  for,  while  the  scalp  can  be  cleaned  and  kept  clean,  the  face, 
edges  of  the  nostrils,  etc.,  where  cracks  in  the  skin  occur,  can  never  be  kept  surgically 
clean.  Here  erysipelas  does  not  differ  from  that  which  is  seen  elsewhere,  except  that 
swelling  is  greater,  and  extension  by  way  of  the  venous  and  lymphatic  channels  from  the 
scalp  to  the  meninges  is  to  be  feared.  The  involvement  of  the  whole  scalp  is,  of  course, 
more  dangerous  than  the  involvement  of  only  a  portion,  for  thereby  more  ways  of  infection 
toward  the  meninges  will  be  involved.  In  negroes  the  blush  of  erysipelas  will  not  be  appar- 
ent if  the  patient  be  dark-hued.  Great  swelling  of  the  ears  occurs,  and  the  eyelids  resem- 
ble bladders  of  water  if  they  become  involved  in  the  disease.  Medication  will  not  differ 
from  that  called  for  in  the  condition  occurring  elsewhere  in  the  body.  The  reader  is  re- 
ferred to  the  chapter  on  Surgery  of  the  Skin,  in  Volume  II.  of  this  work. 

It  is  untrue  that  sutures  of  the  scalp  differ  from  sutures  elsewhere 
in  being  more  dangerous,  as  they  were  considered  to  be  by  the  older 
writers.  It  was  the  dirty  methods  employed,  and  not  the  sutures,  that 
permitted  erysipelas  to  occur. 

Abscesses  are  met  with  in  the  scalp,  as  elsewhere,  either  single  or 
multiple.     The  usual  symptoms  are  present,  and  early  opening  called 

50 


786  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

for.  The  injection  of  cocain  into  the  skin — 2  per  cent,  solution — will 
render  the  opening  painless. 

Gangrene  of  the  scalp  occurs  in  two  forms :  one,  the  localized 
condition  following  severe  crush  which  interferes  with  the  circulation 
and  gives  rise  to  a  slough  which  is  cast  off,  being  seen  generally  in 
torn  ends  and  flaps  which  have  not  been  trimmed  away  by  the  sur- 
geon ;  the  other  is  the  acute  spreading  form,  characterized  by  gas  in 
the  tissues,  and  tending  rapidly  to  constitutional  sepsis.  This  is  fortu- 
nately a  very  rare  disease,  and,  if  successfully  treated  at  all,  is  to  be 
treated  by  deep  and  extensive  incisions  followed  by  continuous  irri- 
gation, and  if  this  is  not  possible,  then  by  frequently  changed  com- 
presses wet  with  weak  corrosive-sublimate  solutions  or  hot  water. 
Hospital  gangrene  may  be  met  with  in  the  scalp. 

Carbuncle  is  seen  on  the  scalp  as  an  extension  from  the  neck, 
where  it  is  often  found.  As  a  primary  disease  of  the  scalp  it  calls  for 
immediate  curetting. 

Ulcers  of  the  scalp  are  seldom  met  with  save  as  an  evidence  of 
syphilis.  The  well-known  line  at  the  border  of  the  hair  in  front  may 
be  taken  as  an  example.  There  is  a  tendency  for  syphilitic  ulceration 
of  the  scalp  to  occur  in  the  middle  line. 

Tumors  of  the  Scalp. — Hematoma. —Extravasation  of  blood 
under  the  scalp  is  evidence  of  injury,  and  sometimes  gives  a  clue  to 
the  situation  of  a  broken  bone. 

Pneumatocele. — Two  kinds  of  tumors  of  the  scalp  containing  air 
are  met  with.  One  of  these  follows  a  break  in  bone  communicating 
with  the  air-passages — the  nasal  bone  and  the  ethmoid  cells.  When 
the  patient  attempts  to  blow  his  nose,  air  is  forced  into  the  subcuta- 
neous tissue,  causing  emphysema  which  may  extend  over  a  great 
portion  of  the  scalp.  The  ordinary  symptoms  of  emphysema  are 
present,  and  no  harm  need  be  expected  to  follow.  The  air  is  sponta- 
neously absorbed.  With  the  healing  of  the  original  injury  the  ten- 
dency for  the  escape  of  air  into  the  tissues  disappears.  The  other  form 
is  called  pneumatocele,  and  means  a  circumscribed  swelling  containing 
air,  which  swelling  is  of  gradual  formation,  and  indicates  a  bony  non- 
traumatic defect — developmental,  perhaps.  The  tumor  is  slowly  devel- 
oped, and  sometimes  the  bony  defect  will  be  found  at  a  distance  from 
the  point  where  the  gaseous  swelling  exists.  Pneumatocele  rarely 
disappears  by  itself  permanently,  but  will  require  incision  and  packing, 
or  an  injection  with  iodin  solution,  as  may  seem  best.  The  most  cer- 
tain way  is  to  close  the  defect  in  the  bone  by  plastic  operation.  A 
watery  tumor  under  the  scalp — cephalhydrocele — will  be  referred  to 
under  Fractures. 

Wens. — The  most  common  tumor  of  the  scalp  is  the  wen,  or 
sebaceous  cyst,  which  may  occur  in  any  situation,  but  is  most 
often  found  beneath  the  hairy  scalp,  single  or  multiple.  They  vary 
from  very  small  ones  to  those  the  size  of  a  fist,  contain  the  usual  seba- 
ceous matter,  are  sometimes  adherent  to  the  skin  at  one  point,  and  in 
most  cases  offer  no  difficulty  of  diagnosis.  Suppuration  is  occasionally 
met  with  in  them  as  the  result  of  infection  from  without,  possibly  by 
means  of  the  duct,  and  after  the  contents  have  been  evacuated  inflam- 
mation  results.     Such  cases   have  been  mistaken  for  epithelioma.     A 


INJURIES  AXD   DISEASES    OF   THE   SCALP. 


787 


wen  is  to  be  removed  by  incision,  care  being  taken  that  the  entire  sac 
is  extracted,  otherwise  the  growth  will  recur.  Unless  the  tumor  is 
very  large,  it  is  only  necessary  to  split  the  skin  freely  and  turn  out  the 
growth ;  where  a  tumor  is  very  soft,  more  care  is  required  to  get  rid 
of  the  sac ;  but  in  either  case  it  will  come  away  without  difficulty,  and 
must  be  removed  in  order  to  avoid  recurrence.  It  is  rarely  necessary 
to  close  the  wound  by  suture.  The  edges  of  the  skin  come  together, 
and  a  pad  of  gauze  held  by  a  bandage  is  sufficient.  The  line  of  inci- 
sion and  the  adjacent  skin  are,  of  course,  to  be  shaved  and  cleansed 
before  operation. 

Dermoid  cysts  are  infrequent  in  the  scalp,  though  often  seen 
under  the  outer  half  of  the  eyebrow,  the  situation  of  a  branchial  fissure. 
They  are  not  adherent  to  the  skin,  which  moves  freely  over  them,  but 
rest  in  a  depression  of  the  skull  which  may  be  so  deep  as  to  suggest 
a  perforation.  To  this  depression  dermoid  cysts  are  adherent.  If  cut 
open,  hair  will  be  found  growing  from  the  inside  of  the  cyst.  Excision 
is  the  only  treatment,  and  if  the  cyst  is  under  the  eyebrow,  an  incision 
in  the  line  of  the  eyebrow  will  leave  but  little  scar.  Occasionally, 
though  rarely,  a  prolongation  of  the  dermoid  cyst  is  found  within  the 
cranium,  and  a  neck  connects  the  two  portions  ;  or  one  may  extend 
from  the  temporal  region  into  the  orbit.  It  is  important  to  differentiate 
between  dermoid  cyst  and  a  protrusion  of  the  brain  or  its  meninges. 
The  diagnosis  will  rest  upon  the  fact  that  the  tumor  is  not  situated  near 
a  suture,  has  no  appreciable  aperture  through  the  skull  under  it,  is  not 
reducible,  does  not  change  its  tension  by  changing  the  attitude  of  the 
patient,  and  is  not  affected  by  sneezing,  crying,  and  especially  sleeping. 


FlG.  396. —  Soft  fibroma  of  the  scalp. 

If  removal  be  performed  aseptically,  even  if  a  protrusion  of  the  brain 
be  present,  no  harm  will  result.  Where  there  is  an  intracranial  and 
an  extracranial  portion  of  the  dermoid  cyst,  the  skull  is  to  be  chis- 
elled away  and  the  intracranial  portion  removed. 

Cutaneous  horns  growing  from  the  scalp  have  been  noted  in  a 
number  of  cases,  and  are  surgical  curiosities.     If  excision  of  the  base 


788  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

of  the  horn  upon  which  it  is  implanted  in  the  skin  be  done  at  the  time 
of  the  operation,  the  tendency  to  return  will  be  reduced  to  a  minimum. 
These  tumors  bear  close  relationship  to  the  papillomata,  and  are  of 
epithelial  origin. 

Fatty  tumors  of  the  Scalp  arc  ran-.  When  superficial,  there  is  little  difficulty  in 
the  diagnosis ;  when  situated  under  the  occipitofrontalis  tendon,  a  diagnosis  is  impossible 
without  incision.  Those  that  have  fallen  under  my  observation  were  superficial  and  were 
not  difficult  of  recognition.  One  was  situated  just  above  the  occipital  protuberance  in  the 
middle  line,  another  above  the  root  of  the  nose. 

Hard  fibroma  is  rarely  met  with  in  the  scalp,  but  a  soft  fibroma, 
fibroma  molluscum,  is  not  unusual.  Such  growths  are  extremely  vas- 
cular, and  excision  is  to  be  done  after  full  preparation.  The  term 
pachydermatocele  was  given  to  this  form  of  fibroma  by  writers  in  the 
past.  Soft  fibroma  of  the  nerve-sheath  has  been  noticed  on  the  side 
of  the  scalp  near  the  ear.  These  tumors  may  be  very  hairy,  which 
fibroma  molluscum  is  not. 

Keloid. — Keloid  attached  to  the  lobe  of  the  ear  in  the  negro  is 
extremely  common,  but  it  may  appear  at  any  place  where  there  is  a 
scar. 

Teratoma. — This  form  of  tumor  is  found  about  the  head  rarely. 
The  tumor  is  recognized  shortly  after  birth,  and  grows  slowly  at  first. 
From  the  tenth  year  a  more  rapid  increase  is  likely  to  take  place.  The 
shape  and  size  follow  no  rule.  A  diagnosis  is  reached  by  excluding 
other  forms  of  growth. 


FlG.  397. — Teratoma  over  the  occipital  bone. 

The  example  presented  herewith  (Fig.  397}-  was  successfully  removed  from  a  child  aged 
fourteen  in  whom  the  growth  was  noticed  during  the  first  year  and  grew  very  slowly.  After 
the  tenth  year,  however,  growth  was  apparent,  and  during  the  eighteen  months  before  opera- 
tion was  rapid.  The  tumor  was  found  to  contain  bone  and  cartilage,  striated  muscular  fiber, 
and  one  joint  which  resembled  the  shoulder-joint  somewhat. 


INJURIES  AND   DISEASES   OF   THE   SCALP. 


789 


Anthrax  of  the  Scalp. — Anthrax  of  the  scalp  is  very  rare  in 
America,  although  it  is  probably  met  with  more  often  about  the  face 
than  anywhere  else.     The  usual  symptoms  will  be  present. 

In  a  case  recently  in  the  writer's  care  infection  was  at  the  back  of  the  neck  close  to  the 
edge  of  the  hair,  and  much  edema  extended  to  and  involved  the  scalp  (Fig.  398). 

Vascular  Tumors. — Aneurysm  of  the  scalp  is  rare,  usually  con- 
cerns the  temporal  artery,  and  from  its  situation  is  easily  amenable  to 
treatment.  Cirsoid  aneurysm  may 
be  so  extensive  as  to  involve  much 
of  the  scalp.  When  adjacent 
arterial  trunks  are  enlarged  and 
unite,  forming  a  pulsating  tumor 
with  small  arteries  and  capillaries 
pulsating,  the  growth,  fortunately 
rare,  is  called  aneurysm  by  anasto- 
mosis. There  is  a  distinct  bruit, 
which  will  disappear  when  press- 
ure is  made  on  all  the  afferent 
trunks.  Pressure  closing  the  ves- 
sels is  the  most  simple  method 
of  treatment,  but  at  the  same 
time  one  which  rarely  is  success- 
ful. Ligature  of  the  vessels  affer- 
ent to  the  tumor,  with  the  usual 
aseptic  precautions,  will  give  a 
good  result ;  should  recurrence 
take  place,  it  may  be  expedient  to 
dissect  out  the  whole  tumor.  Com- 
munication between  an  artery  and 
a  vein  will  give  rise  to  dilatation 
and  varicose  aneurysm,  a  condition 
which  was  not  infrequently  seen  at  the  bend  of  the  arm  when  phleb- 
otomy was  popular.  If  the  communication  between  the  two  vessels- 
can  be  found,  it  is  to  be  closed  by  ligature,  and  a  favorable  outcome 
follows.  The  dilatation  of  a  sinus  within  the  head,  protruding  under 
the  scalp  through  a  deficiency  of  bone,  is  referred  to  elsewhere ;  the 
superior  longitudinal  sinus  is  always  at  fault. 

Blood-tumors  of  the  Scalp. — A  blood-tumor  under  the  scalp 
may  occur  as  an  injury  at  any  time,  but  is  met  with  in  the  new-born 
under  the  name  of  cephalhematoma,  and  may  give  rise  to  a  suspicion 
that  there  is  a  protrusion  from  within  the  skull,  or  that  a  fracture  of  the 
skull  during  birth  has  taken  place. 

Malignant  Tumors  of  the  Scalp. — Epithelioma  is  most  fre- 
quently seen,  is  met  with  in  middle  or  advanced  life,  and  presents  the 
usual  appearance  and  characteristics.  It  is  likely  that  the  subject  of 
the  growth  will  show  scaly  patches  on  the  face.  Extirpation  means 
not  only  that  the  scalp  is  to  be  removed,  but,  if  necessary,  subjacent 
bone  also,  so  as  to  get  rid  of  the  disease  ;  after  which,  by  plastic  opera- 
tion or  by  grafting,  deficiency  in  the  skull  and  scalp  is  to  be  made 
good.     Secondary  growths  may  appear  in  the  scalp — protrusions  from 


FlG.  398. — Anthrax  ;  scalp  very  edematous. 


790  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

within  the  skull  or  outgrowths  from  the  cranial  bones — but  they  present 
no  features  requiring  mention  here. 

INJURIES  AND  DISEASES  OF  THE  SKULL. 

Contusions  of  the  Skull  and  Incised  Wounds  not  Pene- 
trating" the  Skull. —  The  troubles  which  in  the  past  have  resulted 
from  contusions  and  non-penetrating  injury  to  the  skull  have  been 
largely  caused  by  infection,  which  at  the  present  day  it  is  expected  will 
not  be  met  with. 

Non-inflammatory  Conditions  of  the  Skull. — At  birth  the 
skull  is  but  incompletely  ossified,  and  the  amount  of  bone-deficiency 
may  vary.  Islands  of  bone  are  met  with  in  fibrous  tissue,  and  lines  of 
suture  or  quite  large  areas  of  fibrous  tissue  may  exist  with  no  bony 
islands  whatever.  This  condition  very  rarely  persists  ;  ossification  and 
gradual  closing  in  of  the  skull  are  the  rule.  Where  defective  ossifica- 
tion is  permanent,  a  protrusion  from  within  the  skull  may  take  place, 
constituting  encephalocele \  meningocele,  or  sinus  protrusion. 

Great  variations  exist  in  the  thickness  of  different  skulls  as  well  as  between  different  parts 
of  the  same  skull.  Prom  the  twenty-fifth  to  the  fiftieth  year  the  skull  is  thickest ;  then 
gradual  atrophy  occurs,  until  in  extreme  age  the  cranial  bones  may  be  very  thin.  This  is 
due  to  an  absorption  of  the  diploe  and  a  consequent  fusion  of  the  two  tables  of  the  skull. 
The  skull  of  the  negro  is  thicker  than  that  of  the  white  race.  Occasionally,  however,  with- 
out known  cause,  the  bones  will  be  found  unduly  thick,  even  massive,  without  diminishing 
the  capacity  of  the  brain-cavity.  As  the  result  of  rickets  (craniotabes),  open  fontanels, 
wide  sutures,  irregular  ossification,  protuberant  forehead,  and  a  softness  of  the  bones  which 
permits  of  yielding  under  pressure  are  met  with.  Under  such  conditions  no  local  treatment 
is  indicated  in  addition  to  what  may  be  required  for  the  general  disease. 

Inflammatory  Conditions  of  the  Skull. — Acute  inflammation 
of  the  periosteum  is  the  result  of  injury  with  acute  infection,  and  is  char- 
acterized by  the  usual  symptoms  of  periostitis.  It  is  more  often 
encountered  on  the  sides  of  the  head,  in  the  neighborhood  of  the  ears. 
A  rigor,  fever,  and  the  usual  symptoms  of  inflammation,  local  and  gen- 
eral, are  present.  Pus  becomes  diffused  under  the  tendon  of  the  occip- 
itofrontalis,  which  is  raised  and  gives  free  fluctuation.  Pus  tends  to 
sink  down  in  the  zygomatic  fossa  and  point  near  the  angle  of  the  jaw. 
If  the  temporal  muscle  is  involved  in  the  inflammatory  process,  the 
motion  of  the  lower  jawr  is  affected.  Phlebitis  and  the  extension  of 
the  inflammation  to  the  interior  of  the  cranium  through  the  medium 
of  communicating  veins  may  result.  Free  incision  is  called  for  as 
soon  as  a  diagnosis  is  made.  A  voluminous  dressing  of  gauze  wrung 
out  in  hot  water  is  to  be  applied  and  changed  frequently,  and  the  case 
treated  like  an  acute  bone-inflammation  elsewhere.  The  flap  of  soft 
parts  which  has  been  raised  from  the  cranium  by  the  pus  usually  read- 
heres  ;  but  this  is  not  alwrays  the  case,  and  superficial  caries  of  bone  may 
result.  Chronic  inflammation  of  the  vault  of  the  cranium  is  met  with, 
but  it  is  rarely  painful,  is  always  slow  in  its  progress,  and  is  very  apt  to 
be  tubercular  or  syphilitic.  When  tubercular,  it  calls  for  free  opening 
and  curetting ;  iodoform  dressing  should  be  employed.  Injection  of 
an  iodoform  emulsion  into  the  cold  abscess  is  sometimes  of  advantage. 
Osteomyelitis  of  the  bones  of  the  head  is  very  rare.  In  diffused  form 
it  is  rapidly  fatal,  pyemia  or  an  extension  of  inflammation  from  the 
bones  to  the  meninges  resultinsr. 


INJURIES  AND   DISEASES   OF   THE   SKULL. 


79I 


The  treatment  will  be  that  given  in  osteomyelitis  elsewhere — 
namely,  very  free  opening  through  the  soft  parts,  and  cutting  by  chisel 
or  by  trephine  to  the  extent  that  may  seem  proper.  The  tendency 
of  such  an  osteitis  is  to  extend  toward  the  meninges  rather  than 
toward  the  surface;  in  either  case  a  sequestrum  may  form,  which 
separates  slowly.  Gumma  of  the  cranial  bones  is  not  unusual,  and 
may  result  in  perforation.  Extensive  sequestra  form,  exposing,  after 
removal,  extensive  areas  of  granulating  dura.  Under  antisyphilitic 
treatment  the  prognosis  is  fairly  good.  Sequestra  should  be  re- 
moved. The  shape  of  such  a  sequestrum  is  generally  rounded,  with 
irregular  edges.  The  process  of  separation  is  very  slow.  There  will 
exist  one  or  more  openings  through  the  scalp,  giving  exit  to  a  very 
profuse  discharge.  If  a  portion  of  the  skull  through  which  cranial 
nerves  pass  becomes  involved,  paralysis  follows.  Fatal  inflammation 
of  the  meninges  rarely  supervenes. 

Injuries  in  utero  or  during  birth,  from  pressure,  are  occasionally 
recognized.  It  is  a  question  whether  epilepsy  in  childhood  may  not  owe 
its  origin  to  some  such  injury.  The  peculiarly  shaped  heads  occasion- 
ally met  with  in  young  children  may  result  from  birth-pressure. 

Osteomata  of  the  skull  are  very  rare,  and  may  occur  either  externally 
or  internally.  The  latter  are  called  enostoses,  and  interference  with  the 
functions  of  important  parts  of  the  brain  may  result  from  them. 
Exostoses  are  not  so  infrequent  and  are  of  ivory  hardness.  In  the 
orbit  an  outgrowth  of  bone  is  met  with.  They  are  commoner  during 
the  early  years  of  life,  and  cease  to  increase  when  the  skeleton  has 


FlG.  399. — Osteoma  of  the  frontal  bone. 


attained  its  growth.  The  differential  diagnosis  between  osteosarcoma 
and  osteoma  is  rarely  difficult  (Fig.  399).  The  length  of  time  during 
which  the  symptoms  may  have  existed  usually  permits  a  diagnosis  to 
be  made,  even  though  the  bone-tumor  project  into  a  cavity  so  as  not 
to  be  under  the  surgeon's  fingers.  Where  the  bone  projects  outwardly 
there  is  no  difficulty  in  diagnosis. 


792 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


Sarcoma  may  develop  in  the  skull  as  a  primary  or  a  secondary 
growth.  The  diagnosis  is  not  difficult,  although  in  its  early  stages 
such  a  growth  may  be  mistaken  for  a  gummatous  tumor.  Pulsation, 
if  vascular,  bruit,  and  rapid  growth  will  establish  the  diagnosis  (Fig. 
400).     Where  a  sarcoma  of  the  skull  grows  inward,  rapid  interference 


Fig.  400. — Sarcoma  of  the  skull  secondary  to  sarcoma  of  the  jaw. 

with  the  functions  of  the  brain  is  to  be  expected.  Its  increase  may  be 
at  first  either  slow  or  fast,  but  sooner  or  later  rapid  increase  takes  place. 
Sarcoma  of  the  skull  is  probably  traumatic  in  a  number  of  cases.  The 
treatment  is  free  excision  together  with  removal  of  adjacent  parts.  The 
difficulty  of  effecting  this  is,  of  course,  evident.  If  the  growth  is  large, 
nothing  can  be  done ;  if  small,  removal  of  the  bone  from  which  the 
growth  starts  and  the  covering  in  of  the  defect  by  bone  from  elsewhere 
are  expedient. 

Carcinoma  of  the  Skull. — Carcinoma,  being  an  epithelial  prod- 
uct, occurs  in  the  skull  only  secondarily. 

I^eontiasis. — This  name  is  given  to  a  diffuse  enlargement  of  the 
cranial  bones.  Its  name  and  the  appearance  of  the  skull  strongly 
suggest  tubercular  leprosy. 

Myxoma. — These  tumors  are  seen  sometimes  springing  from  the 
basilar  process,  and  may  completely  block  the  cavity  of  the  mouth. 
Their  removal  is  usually  attended  with  excessive  hemorrhage. 

CEREBRAL  LOCALIZATION. 

There  are  certain  areas  upon  the  cortex  of  the  brain,  not  necessarily 
co-extensive  with  either  lobes  or  convolutions,  whose  functions  are 
accurately  known.  These  areas  are:  1.  The  sensorimotor  area.  2. 
The  speech  areas.  3.  The  visual  area.  4.  The  auditory  area.  5. 
The  area  of  sensations  of  smell  and  of  taste. 


CEREBRAL   LOCALIZATION. 


793 


The  sensorimotor  area  includes  the  cortex  of  the  anterior  and  pos- 
terior central  convolutions  which  border  the  fissure  of  Rolando  and 
the  adjacent  cortex  in  front  of  and  behind  these  convolutions.  Each 
hemisphere  controls  movement  on  the  opposite  side  of  the  body ;  but 
as  the  right  hand  is  more  generally  used  and  is  better  trained  than  the 
left,  this  area  is  larger  on  the  left  hemisphere  than  on  the  right. 

The  cortex  of  the  posterior  part  of  the  second  frontal  convolution 
controls  the  movements  of  the  eyes  and  head.  Impulses  starting  from 
this  area  produce  conjugate  movement  of  these  parts  toward  the  oppo- 
site side.  The  eye  district  is  below,  the  head  district  above.  The 
lower  third  of  the  anterior  and  posterior  central  convolutions  governs 
the  movements  of  the  face,  tongue,  larynx,  and  pharynx.  The  eye- 
brows and  cheeks  are  controlled  by  the  upper  and  forward  part  of  this 


FlG.  401. —  Functional  areas  of  the  cerebral  cortex  on  the  right  side  (Dercum). 

area ;    the  tongue  and  larynx,  by  the  lower  and   forward   part ;    the 
mouth,  pharynx,  and  platysma,  by  the  hinder  part. 

The  middle  third  of  the  anterior  and  posterior  central  convolutions 
governs  the  movements  of  the  upper  extremity,  the  shoulder-motions 
being  controlled  in  the  anterior  and  upper  part  of  this  area,  the  elbow- 
motions  in  its  middle  part,  and  the  hand-  and  finger-motions  in  its  pos- 
terior and  lower  part.  The  upper  third  of  the  anterior  and  posterior 
central  convolutions,  including  their  junction  in  the  paracentral  lobule, 
controls  the  motions  of  the  lower  extremity,  the  thigh,  knee,  foot,  and 
toes  being  governed  by  various  parts  of  this  area  from  before  back- 
ward in  the  order  named. 

It  will  be  noticed  that  the  parts  susceptible  of  the  finest  and  most  delicate  movements, 
those  directed  by  the  most  acute  sensations — the  lips,  the  fingers,  and  the  toes — lie  farthest 
back  in  the  motor  area,  chiefly  in  the  posterior  central  convolution.  Lesions  in  this  convo- 
lution almost  always  cause  some  loss  of  tactile  sensation  in  addition  to  paralysis,  and  hence 
this  area  is  thought  to  be  the  seat  of  tactile  sensations  as  well  as  of  movements. 

There  are  no  sharply-defined  sections  of  the  motor  area  to  be 
assigned  to  special  motions.     Each  motion,  each  part  of  a  limb,  has  a 


794 


INTERNATIONAL    TK. XT-BOOK  OJ-    SURGERY. 


wide  general  representation  over  the  cortex  and  a  special  representa- 
tion at  a  limited  area.  Horsley  says  that  the  areas  of  representation 
of  different  limbs  merge  into  one  another;  thus,  in  the  representation 
of  the  thumb  we  find  that  there  is  a  focus,  but  that  the  thumb  is  rep- 
resented over  a  great  deal  of  the  upper-limb  region,  and  that  this  rep- 
resentation diminishes  in  intensity  gradually  as  we  pass  from  the  focus 
upward.  This  explains  the  fact  that  the  excision  of  a  small  area  does 
not  totally  paralyze  the  portion  of  the  limb  represented  chiefly  on  that 
area.  The  adjacent  areas  represent  to  some  extent  that  limb,  and 
hence  can   govern  it  if  need  be. 

The  speech-areas  are  of  four  kinds  and  in  four  locations.  They  are 
limited  to  the  left  hemisphere  in  right-handed  persons  and  to  the  right 
hemisphere  in  left-handed  persons.  There  is  the  motor  speech-area  in 
the  posterior  part  of  the  third  frontal  convolution,  in  which  the  move- 
ments concerned  in  the  act  of  speaking  are  controlled.  The  use  of 
language  and  the  power  of  talking  are  affected  when  this   region  is 


FlG.  402. — Functional  areas  of  the  cerebral  cortex  on  the  left  side  (Dercum). 

destroyed.  There  is  the  auditory  speech-area  in  the  first  and  second 
temporal  convolutions,  in  which  the  memories  of  word-sounds  are 
stored  up.  The  understanding  of  language  and  the  power  of  recol- 
lecting the  names  of  objects  are  lost  when  this  region  is  destroyed. 
There  is  the  visual  speech-area  in  the  lower  parietal  region,  in  which 
the  memories  of  printed  words  are  stored  up.  The  understanding  of 
written  language  and  the  power  to  read  are  lost  when  this  region  is 
destroyed.  The  power  of  writing  is  a  part  of  speech,  and  is  usually 
lost  when  the  motor  speech-area  is  destroyed,  but  its  exact  location  is 
not  fully  determined ;  some  cases  point  to  the  second  frontal  convo- 
lution, others  to  the  lower  parietal  convolution  near  the  hand-center,  as 
its  probable  cortical  position. 

The  area  of  sensations  of  sight  is  located  in  the  occipital  lobe  of  the 
brain,  including  the  cuneus  on  the  median  surface  and  the  occipital 
convolutions    on    the  convexity.     The    cortex   lying   in   the    calcarine 


CEREBRAL   LOCALIZA TION. 


795 


fissure  is  the  part  primarily  reached  by  the  visual  impulses,  but  the 
parts  named  are  also  concerned  in  vision.  Each  occipital  lobe  receives 
impressions  from  one  half  of  both  eyes,  hence  a  lesion  in  one  lobe 
produces  hemianopsia,  a  half-blindness  in  both  eyes,  the  blind  field  of 
vision  being  on  the  opposite  side  to  the  lesion. 

The  area  of  sensations  of  sound  is  located  in  the  first  and  second 
temporal  convolutions  of  the  brain.  Each  ear  is  connected  with  both 
hemispheres ;  hence  deafness  from  a  unilateral  lesion  is  only  partial, 
and  is  not  generally  noticed.  On  the  other  hand,  if  both  temporal 
lobes  are  destroyed,  the  patient  becomes  totally  deaf. 

The  area  of  sensations  of  smell  and  taste  is  located  at  the  tip  of  the 
temporal  lobe,  on  its  under  and  inner  surface,  which  rests  on  the 
sphenoid  bone.  Each  lobe  is  related  to  sensory  organs  on  both  sides, 
and  a  unilateral  lesion  does  not  often  produce  noticeable  symptoms. 

There  appears  to  be  a  certain  relation  between  the  frontal  lobes 
of  the  brain  and  the  higher  forms  of  intellectual  activity,  the  powers 
of  fixing  the  attention  and  of  reasoning  and  self-control ;  but  disease 


Fig.  403. — Median  surface  of  the  right  hemisphere  (after  Ecker). 


here  does  not  cause  a  loss  of  any  one  mental  faculty,  and  for  the 
higher  powers  of  the  mind  a  general  integrity  of  the  entire  brain,  not 
of  any  one  part,  is  necessary.  When  it  is  considered  that  every  con- 
cept is  made  up  of  numerous  memory-pictures  joined  together,  each 
of  which  has  a  separate  location  in  the  brain-cortex,  it  becomes  evi- 
dent that  to  the  process  of  thought  a  healthy  state  of  the  entire  cortex 
is  necessary,  and  also  of  the  white  matter  beneath  it,  through  which 
the  associating  fibers  pass.  It  is  therefore  impossible  for  a  single 
lesion  anywhere  to  cause  a  loss  of  memory,  or  of  imagination,  or  of 
judgment.  Yet  for  the  co-ordination  of  facts  into  orderly  series,  for 
comparison,  and  for  analysis  of  knowledge  gained  through  the  senses 
a  healthy  state  of  the  frontal  lobes  appears  to  be  necessary.  Lesions 
in  the  frontal  region,  especially  upon  the  left  side,  are  quite  uniformly 
attended  by  mental  dulness,  apathy,  lack  of  power  of  concentration, 
and  imperfect  self-control. 

The  cortex  of  the  hemispheres  upon  the  base  of  the  brain  lying  on 
the  orbital  plate,  on  the  sphenoid  and  temporal  bones,  and  on  the  ten- 


796  INTERNATIONAL    TEXT-BOOK    OF  SURGERY. 

torium  cerebelli  has  as  yet  no  assignable  functions,  and  lesions  in  these 
regions  do  not  produce  recognizable  symptoms. 

The  crura  cerebri,  pons,  and  medulla  contain  the  centers  of  the 
various  cranial  nerve-nuclei,  and  hence  cranial  nerve-palsies  are  caused 
by  disease  in  them.  They  transmit  motor  and  sensory  tracts  to  the 
spinal  cord,  hence  numerous  symptoms  appear  when  they  are  injured. 

The  cerebellum,  lying  in  the  posterior  cranial  fossa  beneath  the 
tentorium  cerebelli,  controls  the  equilibrium  of  the  body ;  hence  dis- 
turbances of  the  nature  of  staggering  and  vertigo  are  produced  by 
lesions  affecting  it,  especially  if  its  median   lobe  is  involved. 

It  will  thus  be  seen  that  cerebral  localization  has  to  do  mainly 
with  two  fissures — the  fissure  of  Rolando  and  the  fissure  of  Sylvius. 
It  is  important  that  the  relation  between  the  external  surface  and  the 
various  cerebral  convolutions  should  be  capable  of  recognition  ;  other- 
wise, operations  undertaken  through  the  skull  would  necessarily  be 
much  in  the  dark.  To  find,  then,  the  fissure  of  Rolando  the  following 
method  is  to  be  adopted :  Trace  a  line  along  the  vertex  from  the  root 
of  the  nose  to  the  posterior  occipital  protuberance,  and  find  the  mid- 
dle of  this  line.  From  a  point  \  inch  posterior  to  this  middle  spot 
draw  a  line  downward  and  forward,  making  an  angle  of  67  degrees 
with  the  middle  line.  This  line  will  lie  over  the  fissure  of  Rolando. 
Two  metal  strips  joined  at  an  angle  of  67  degrees  are  usually  employed 
to  find  the  Rolandic  fissure,  the  place  of  joining  being  made  to  corre- 
spond with  the  point  already  referred  to.  If  one  limb  of  the  angle  be 
placed  along  the  median  line,  the  other  will  correspond  to  the  Rolandic 
fissure.  The  Rolandic  fissure  is  about  3^  inches  long,  and  the  lower 
end  of  it  dips  rather  suddenly  down  from  the  middle  line,  and  there- 
fore the  last  half-inch  does  not  quite  correspond  to  the  strip  of  metal. 
The  fissure  of  Sylvius  is  found  as  follows  :  From  the  lower  margin  of 
the  orbit  to  the  external  auditory  meatus  a  line  is  to  be  drawn.  Draw 
a  second  line,  parallel  with  the  preceding,  from  the  external  angular 
process  of  the  frontal  bone  backward  1^  inches,  then  upward  from 
the  end  of  this  \  inch  ;  mark  this  point  1.  From  the  top  of  the  pari- 
etal eminence  draw  a  line  downward,  perpendicular  to  the  base  line, 
and  mark  a  point  \  inch  below  the  eminence ;  this  is  point  2.  Join 
points  1  and  2,  and  the  line  will  lie  over  the  fissure  of  Sylvius.  The 
Sylvian  fissure  is  about  4  inches  long. 

CONTUSION  AND  CONCUSSION  OF  THE  BRAIN. 

This  is  met  with  to  a  greater  or  less  extent  as  an  accompaniment  of 
violence  to  the  skull.  Mild  concussion  occurs  without  structural 
change  of  the  brain.  Where  the  concussion  is  greater,  it  will  be  proper 
to  use  the  word  "  contusion  "  to  indicate  the  cerebral  injuries,  which 
may  be  small  capillary  hemorrhages.  This  may  take  place  with  or 
without  fracture  of  the  cranium.  The  contused  portions  of  the  brain 
may  soften  or  be  absorbed,  scar-tissue  subsequently  resulting.  It  is 
rare  for  abscesses  to  form,  since  bacteria,  in  the  absence  of  a  wound, 
could  reach  the  injured  locality  only  by  the  circulation. 

Contusions  of  the  brain  occur  not  only  at  the  point  struck  but  at  the 
opposite  side — counter-stroke — -of  the  skull.     Contused  areas  also  occur 


CONTUSION  AND    CONCUSSION  OF  THE  BRAIN.  797 

in  other  portions  of  the  brain  than  those  immediately  opposite  the  seat 
of  injury.  A  still  more  extensive  injury  to  the  brain  than  "  contusion  " 
is  called  a  "  laceration."  In  this  the  amount  of  hemorrhage  may  be 
increased,  so  as  to  justify  the  term  "intracranial  hemorrhage."  It  is 
not  always  possible  to  differentiate  between  concussion  and  contusion 
in  their  varying  degrees.  Contusion  necessarily  implies  concussion, 
but  concussion  may  exist  without  contusion.  There  are  several  theories 
as  to  the  cause  of  concussion — one,  that  the  vibration  is  transmitted 
to  the  brain,  another  that  the  fluid  within  the  ventricles  is  violently 
displaced — both  of  which  are  accepted  by  eminent  authorities. 

The  symptoms  present  will  vary  with  the  injury  to  the  brain. 
After  a  concussion  with  momentary  unconsciousness  the  patient  may 
recover  promptly  and  go  on  with  his  vocation.  A  more  severe  con- 
cussion is  followed  by  a  period  of  unconsciousness,  feeble  circulation, 
pale  surface,  and  relaxation  of  the  muscular  system,  from  which  recovery 
is  slower.  Vomiting  may  take  place  with  the  beginning  of  recovery. 
Relaxation  of  the  sphincters  occurs  rarely,  and  only  when  the  concus- 
sion is  severe.  Dissimilarity  between  the  symptoms  on  the  two  sides 
of  the  body  will  indicate  something  more  than  concussion — a  contu- 
sion with  injury  to  one  hemisphere  more  marked  than  the  other.  The 
greater  the  contusion  to  the  brain  and  the  greater  the  effusion  of  blood, 
the  more  slowly  will  the  patient  recover.  Recovery  may  be  preceded 
by  delirium,  mental  disturbance,  and  excitement.  Should  any  portion 
of  the  brain,  however,  suffer  special  injur}',  the  symptoms  will  point  to 
that  part.  When  contusion  and  disorganization  of  brain-substance 
have  taken  place,  not  only  will  shock  be  prolonged,  but  repair  may  be 
expected  to  take  place  slowly,  varying,  of  course,  with  the  amount  of 
contusion.  The  function  of  that  part  of  the  brain  which  suffered  con- 
tusion may  be  permanently  impaired.  The  contusion,  if  the  violence  be 
great,  may  go  on  to  the  extent  of  laceration  and  destruction  of  a  suf- 
ficient amount  of  brain-substance  to  produce  death. 

The  diagnosis  between  concussion,  contusion,  and  apoplexy  is  one 
of  degree,  and  unless  the  symptoms  indicate  injury  to  a  definite  region 
of  the  brain,  it  may  be  difficult.  The  symptoms  mentioned  under  the 
head  of  Intracranial  Hemorrhage  must  be  held  in  mind.  The  tempera- 
ture in  concussion  will  probably  be  subnormal ;  in  contusion,  unless 
immediately  after  the  receipt  of  the  injury,  the  temperature  will  be  a 
little  elevated,  and  may  be  expected  not  to  fall  to  normal  at  once,  the 
time  depending  upon  the  amount  of  intracranial  lesion.  From  alcohol- 
ism the  diagnosis  of  concussion  depends  largely  upon  the  ability  of  the 
physician  called  to  see  the  patient  to  recognize  the  odor  of  alcohol 
upon  the  patient's  breath.  Yet  alcoholic  patients  are  frequent  subjects 
of  concussion,  owing  to  their  inability  to  retain  their  equilibrium. 

The  coma  of  uremia  must  be  differentiated  from  intracranial  violence 
as  well  as  from  alcoholism.  The  rule  should  be  absolute  that  the 
urine  of  an  unconscious  patient  brought  into  hospital  should  be  exam- 
ined at  once,  a  catheter  being  used.  Should  no  urine  be  present  in  the 
bladder,  the  clothes  of  the  patient  will  show  whether  any  has  been 
passed  recently  ;  and  in  the  absence  of  urine  either  in  the  bladder  or  on 
the  clothing  a  strong  suspicion  of  uremia  is  aroused.  If  urine  is  found 
to  contain  albumen  and  casts,  etc.,  the  diagnosis  is  made.     Of  course, 


798  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

it  is  not  impossible  that  a  uremic  patient  may  fall  and  hurt  his  head,  but 
the  uremia  is  the  important  point.  An  injured  man,  if  transported  a 
certain  distance,  his  body  lightly  clad  and  exposed  to  cool  air,  will 
show  albuminous  urine  when  he  enters  hospital,  yet  by  the  next  day  it 
may  not  be  present.  This  is  due  undoubtedly  to  the  chilling  of  the 
surface. 

Treatment. — A  diagnosis  is  first  made,  if  possible,  then  reaction 
is  to  be  induced  by  proper  methods,  but  should  not  be  allowed  to  be 
too  violent.  Rest  in  a  recumbent  posture  is  required  with  the  head 
low,  if  the  pulse  be  weak,  and  hypodermics  of  strychnin.  If  the  sur- 
face be  cold,  dry  heat  should  be  applied.  As  the  symptoms  improve 
or  the  reverse,  so  will  treatment  be  changed.  Large  hot  enemata  of 
water  containing  two  ounces  of  black  coffee  seem  to  be  beneficial  where 
collapse  is  profound.  The  amount  of  strychnin  which  can  be  given 
under  such  circumstances  is  large :  -fa  gr.  every  half  hour  until  four 
doses  have  been  given.  For  restlessness,  laudanum  in  a  little  black 
coffee,  say  2  or  3  drops  every  quarter  of  an  hour,  is  given  by  the 
mouth.  If  the  unfavorable  symptoms  be  not  relieved,  the  foot  of  the 
table  may  be  elevated,  but  only  when  symptoms  of  brain  anemia  are 
present.  If  the  symptoms  still  fail  to  improve,  it  is  possible  that  some 
sign  pointing  to  a  definite  portion  of  the  brain  may  appear,  and  to  this 
the  surgeon  should  direct  his  treatment. 


FRACTURES. 

Anatomical  Considerations. — The  cranium  is  made  up  of  bones 
intimately  united  along  certain  lines  of  suture,  which  permit  of  no  move- 
ment between  adjacent  bones  save  in  the  very  young  child.  These 
bones,  especially  in  the  base  of  the  skull,  are  perforated  so  as  to  per- 
mit the  passage  of  important  structures.  The  spinal  canal  joins  the 
cranial  cavity  at  the  foramen  magnum.  The  bones  of  the  vault  of  the 
cranium  are  made  up  of  two  plates  of  bone  with  intervening  cancel- 
lated structure,  the  outer  table  thick  and  strong,  the  inner  table  thin 
and  brittle. 

The  amount  of  cancellated  tissue  varies  with  age.  Wanting  in  early  childhood,  in  adult 
life  it  is  found  in  its  greatest  extent,  and  then  by  absorption  diminishes  in  old  age.  Hence 
in  the  very  young  and  the  aged  the  cranium  is  thinnest.  There  is  a  notable  difference  in 
the  thickness  of  the  bones  forming  different  skulls,  and  this  apparently  without  the  existence 
of  disease.  In  early  childhood  the  bones  move  somewhat  upon  each  other ;  during  and 
after  youth,  not  at  all.  The  sides  of  the  head,  the  squamous  portion  of  the  temporal  bones, 
have  little  or  no  diploe.  The  base  of  the  skull  is  composed  of  cancellated  structure  almost 
entirely,  thin  plates  of  bone  only  covering  in  the  cancellated  structure.  Air-cells  are 
developed  during  adolescence  and  adult  life  in  certain  portions  of  the  skull — for  instance, 
the  frontal  and  ethmoid  sinuses.  These  sinuses  do  not  diminish  in  size  with  advancing  years 
as  does  the  cancellated  tissue  in  the  vault  of  the  cranium,  but  remain  permanently.  The 
free  communication  of  veins  between  the  inside  and  the  outside  of  the  skull  has  been 
referred  to  already. 

Incomplete  fractures — that  is,  fractures  not  extending  through  both 
tables — are  rarely  met  with  except  where  the  frontal  sinuses  exist. 
As  there  is  separation  here  between  the  two  tables,  much  injury  may 
be  done  to  the  forehead  and  yet  the  brain-box  not  be  broken.  If  the 
fracture  of  the  frontal  sinuses  be  compound,  the  secretion  from  the 
mucous  membrane  lining  the  sinus  may  be  mistaken  for  brain-tissue. 


FRACTURES.  799 

Incomplete  fractures  of  the  cranium  elsewhere  are  usually  the  result 
of  knife-  or  sabre-wounds  delivered  with  much  violence,  which  shave 
off  a  flap  of  cranium  and  bone  together.  Incomplete  fracture  is  of 
importance  only  so  far  as  it  has  to  do  with  the  complications,  such  as 
sepsis,  for  instance.     Fractures  of  the  inner  table  are  referred  to  later. 

Fractures  of  the  cranium  are  considered  under  the  heads  of  Simple, 
Compound,  Comminuted,  Complicated,  Complete  or  Incomplete,  Direct 
or  Indirect,  Fissured,  etc.,  as  are  other  fractures ;  but  it  must  be  kept 
in  mind  that  every  fracture  of  the  cranium  is  complicated  by  the  close 
vicinity  of  the  brain  and  its  coverings,  and  that  it  differs  in  this  respect 
from  fracture  of  other  parts.  The  shape  of  the  skull,  as  a  whole,  being 
roughly  that  of  a  globe,  it  breaks,  when  subjected  to  violence,  in  a 
manner  quite  different  from  the  skeleton  elsewhere.  Not  only  the 
point  where  the  injury  is  received  may  give  way,  but  the  violence  will 
travel  to  a  distant  region  and  in  some  cases  cause  a  fracture,  the  inter- 
vening bone  remaining  intact.  In  like  manner,  transmitted  violence 
may  be  expended  not  upon  bone,  but  upon  the  dura,  which  closely 
adheres  to  the  inner  surface  of  the  skull,  producing  rupture  of  a  blood- 
vessel and  intracranial  bleeding.  In  other  instances  the  brain  itself 
will  receive  the  violence,  and  disorganization  of  the  nervous  matter 
result.  Injury  to  bone  always  is  to  be  held  of  secondary  importance, 
the  matter  of  first  importance  being  the  injury  to  the  nervous  system. 
This  should  never  be  forgotten. 

Fracture  of  the  Vault  of  the  Cranium. — Fracture  of  the  vault 
is  usually  the  result  of  direct  violence  applied  over  a  limited  surface. 
If,  on  the  other  hand,  violence  is  attended  by  much  momentum,  the 
force  is  diffused,  and  a  fissure  may  be  found  to  travel  from  the  point 
struck  to  some  distant  region.  A  quick  sharp  blow,  then,  produces  a 
local  fracture ;  violence  with  momentum,  a  fissure.  The  direction  in 
which  the  fissure  travels  is  not  always  certain,  and  the  mechanism  by 
which  it  is  produced  is  not  always  plain.  In  injury  to  the  vault  of  the 
cranium  from  without,  the  inner  table  will  be  fractured  over  a  larger 
area  than  the  outer  table,  and  a  comminution  of  the  inner  table  may 
take  place  and  one  or  more  of  the  fragments  be  turned  on  edge,  so  as 
to  irritate  the  adjacent  dura.  If  violence  be  done  from  within  the 
skull,  as  by  a  pistol-bullet  passing  through  the  skull,  at  the  wound  of 
exit  the  outer  table  will  be  broken  over  a  larger  area  than  the  inner. 
As  an  extremely  rare  condition  the  amount  of  violence  may  be  suf- 
ficient to  break  the  inner  table  without  fracture  of  the  outer  table.  An 
example  of  this  is  in  the  Medical  Museum  at  Washington. 

A  sudden  sharp  blow,  breaking  the  vault,  will  depress  the  bone, 
which  gives  way  along  several  lines.  The  amount  of  depression  will 
depend  on  the  violence  and  the  shape  of  the  vulnerating  weapon.  The 
apex  of  the  depression  will  press  against  the  dura,  which  may  give 
way,  so  that  the  brain  is  torn  by  the  rough  bone-edges,  while  the  sides 
of  the  cone-shaped  depression  will  be  the  fragments  of  skull  driven  in 
but  remaining  attached  to  the  unbroken  vault.  Should  the  violence 
be  extreme,  fragments  of  bone  are  detached  from  the  skull  and  driven 
bodily  into  the  brain.  The  inner  table  is  always  more  extensively 
comminuted  than  the  outer  table,  although  the  dura  will  give  way  to  a 
less  extent  than  the  outer  table. 


800  INTERNATIONAL    TEXTBOOK   OF  SURGERY 

Depression  of  bone  sufficient  to  force  in  the  dura  without  causing 
that  membrane  to  give  way  is  liable  to  contuse  the  brain  and  cause 
subdural  hemorrhage.  Permanent  depression  of  bone  without  fracture 
does  not  occur  except  in  very  early  life,  yet  a  portion  of  cranium  may 
be  forced  inward  and  give  way  in  the  line  of  several  fissures,  resuming 
its  normal  position  when  the  force  is  removed;  these  fissures  arc  appa- 
rently insignificant,  yet  they  are  plainly  fractures. 

Fracture  of  the  skull  without  depression  is  apt  to  take  the  shape 
of  a  fissure,  which  may  be  compound,  with  or  without  depression ;  if 
depression  exist,  effusion  of  blood  under  the  intact  scalp  promptly 
fills  the  depression  and  raises  the  scalp  so  as  to  mask  the  injury.  If 
the  scalp  gives  way,  there  is  external  bleeding,  and  the  depressed  bone 
is  plainly  exposed  to  sight  and  touch. 

Brain-shock,  then,  is  to  be  accepted  as  a  first  result  of  injury  to  the 
vault  of  the  cranium  ;  whether  this  shock  be  accompanied  by  hemor- 
rhage or  disorganization  of  the  brain  or  not,  the  observer  will  not  be 
able  at  once  to  recognize.  Depression  of  bone  can  generally  be  made 
out  by  careful  examination,  although  the  scalp  may  not  be  divided. 
If  there  is  much  effusion  about  the  seat  of  injury,  and  the  scalp  is  not 
divided,  recognition  of  the  fracture  is  difficult.  Attention  should  be 
directed  to  the  fact  that  after  an  injury  to  the  scalp  with  effusion  of 
blood  between  the  scalp  and  the  skull,  the  periphery  of  the  effusion 
in  the  course  of  two  or  three  days  becomes  hard,  while  the  center 
remains  still  soft,  thus  giving  to  the  examining  finger  the  sensation 
of  a  depressed  fracture,  when  in  fact  the  bone  is  intact.  Excellent 
surgeons  have  been  misled  by  this.  Gentle  and  steady  pressure  will 
usually  suffice  to  press  aside  any  effusion  or  clot,  and  enable  the  exam- 
ining finger  to  recognize  fracture  if  any  depression  be  present.  Where 
a  fissure  without  displacement  exists,  such  an  examination  is  negative. 
When  a  diagnosis  is  uncertain,  the  surgeon  should  not  hesitate  to 
divide  the  scalp  and  inspect  the  injured  region.  Aseptic  precautions 
are,  of  course,  called  for. 

A  fissure-fracture  starting  from  the  vault  where  injured  will  gener- 
ally travel  toward  the  base,  and  there  is  a  general  tendency  for  fract- 
ures in  the  front  or  middle  or  posterior  part  of  the  vault  to  extend 
toward  the  fossa  at  the  base  of  the  skull  corresponding  to  the  portion 
of  the  vault  injured.  Fissures  of  the  anterior  portion  of  the  skull  are 
apt  to  involve  the  roof  of  the  orbit  and  anterior  fossa;  those  of  the 
posterior  part  of  the  head,  the  cerebellar  fossa;  and  those  of  the  central 
portion  of  the  head,  the  middle  fossa  of  the  base.  The  fissure  which 
begins  by  running  horizontally  will  usually  turn  downward  toward  the 
base,  but  the  mechanism  by  which  longitudinal  fissures  of  the  cranium 
are  produced  is  not  well  defined.  In  depressed  fracture  the  lines  of 
fracture  will,  of  course,  vary  with  the  violence  and  its  direction,  also 
the  amount  of  depression  and  the  amount  of  comminution.  Occasion- 
ally, although  violence  has  come  from  without,  a  fracture  of  the  vault 
of  the  cranium  has  resulted  not  in  a  depressed  but  in  a  raised  fragment 
of  bone.  In  these  cases  a  pointed  missile — chisel — has  entered  the 
skull  and  pried  the  broken  portion  above  the  surrounding  surface. 

Fracture  of  the  base  is  usually  considered  as  occurring  not  by 
direct  violence,  but  rather  by  counterstroke,  contre  coup.     This  latter  is 


FRACTURES.  8oi 

the  case  where  fracture  of  the  base  follows  an  injury  to  the  vault,  the 
intervening  bone  being  intact.  But  where  violence  done  to  the  vault 
results  in  an  injury  which  travels  from  the  point  struck  down  into  the 
base,  in  the  form  of  a  fissure,  it  is  more  accurately  described  not  as 
counterstroke,  but  as  direct  violence  travelling  continuously  along 
the  skull  wall.  The  mechanism  by  which  the  fracture  by  counter- 
stroke  takes  place  has  been  variously,  but  not  always  satisfactorily, 
explained.  The  most  probable  view  at  present  is  that  from  the  point 
where  the  violence  is  received  a  wave  is  transmitted  through  the  semi- 
fluid brain  and  delivered  at  some  distant  point,  producing  a  fracture 
there.  This  would  be  more  easily  understood  if  the  cranium  were  a 
perfect  sphere,  and  the  region  of  the  counterstroke  fracture  were 
always  directly  opposite  where  the  violence  is  first  received.  Such  is 
not  the  case,  however,  and  therefore  various  buttresses  in  the  skull 
itself  are  regarded  as  tending  to  diffuse  shock,  and  thus  produce  fract- 
ure in  a  somewhat  irregular  way.  It  is  considered  that  the  vault  of 
the  cranium  is  ribbed  anatomically,  the  ribs  running  up  toward  the 
vertex  from  the  frontal  region,  the  external  angular  process  of  the 
frontal,  the  mastoid  process,  and  behind  from  the  occipital  protuber- 
ance. In  the  middle  line  in  front,  from  the  root  of  the  nose  upward,  a 
rib  may  be  considered  to  extend,  and  rarely  if  ever  will  a  fracture 
passing  from  the  vertex  downward  follow  these  ribs,  but  always  run 
between  them.  The  transmission  of  violence  along  the  walls  of  the 
cranium  was  at  one  time  the  accepted  theory.  I  scarcely  think  that  at 
the  present  day  any  one  view  of  the  counterstroke  will  be  found  to 
apply  to  all  cases.  Where  the  fissure  starts  from  the  point  struck  and 
extends  continuously  into  a  distant  part  of  the  cranium,  there  is  no 
doubt  that  the  shape  and  consistence  of  the  bone  have  much  to  do 
with  the  line  of  fracture.  Counterstroke  injury  is  not,  however,  limited 
to  bone-tissue,  for  contusion  of  the  brain  and  rupture  of  blood-vessels 
may  occur,  both  of  which  are  of  infinitely  more  importance  than  the 
fracture  of  bone. 

Fissure-fractures  pursue  their  course  independently  of  sutures. 
When  violence  is  done  to  the  vault  of  the  cranium,  it  is  probable  that 
a  certain  amount  of  depression  takes  place,  and  that  the  bone  from  its 
own  elasticity  regains  it  shape.  If  the  violence  is  continued  until  the 
bone  gives  way,  the  bones  may  or  may  not  resume  their  shape.  Wrhere 
a  fissure  has  been  produced  and  the  bones  have  taken  their  position 
again,  diagnosis  without  a  wound  of  the  soft  parts  is  not  possible.  In 
a  certain  number  of  cases  of  this  kind  the  vulnerating  force  has  carried 
hair  against  the  bone  (compound  fractures),  which  hair  has  been  caught 
in  the  fissure,  and,  on  inspection,  appears  to  be  growing  directly  from 
the  bone. 

In  childhood,  when  the  bones  are  softer  and  more  elastic  than  later, 
having  little  cancellated  structure,  a  depression  without  fracture  may 
exist. 

The  roof  of  the  orbit,  when  broken,  gives  way  most  irregularly. 
There  are  instances  of  fracture  of  the  roof  of  the  orbit  where  the 
fracture  was  comminuted  and  the  fragments  were  turned  up  on  edge 
so  as  to  irritate  the  dura.  The  anterior  fossa  of  the  base  has  been 
broken  by  injury  received  on  the  occiput,  counterstroke  giving  rise  to 

51 


8o2  INTERNATIONAL    TEXT-BOOK  OF  SURG/:  RY. 

comminution  of  the  orbit  roof.  The  case  of  a  late  chief  magistrate  of  the 
United  States  who  suffered  fracture  of  both  orbital  plates  from  a  pistol 
bullet-wound  of  the  occipit  has  become  classical.  The  anterior  fossa 
of  the  base  is  occasionally  wounded  by  direct  violence  through  the 
orbit.  Cases  are  recorded  where  an  umbrella-point  or  a  foil  has  been 
thrust  through  the  roof  of  the  orbit,  the  skin-wound  being  so  small  as 
to  escape  notice,  so  that  the  fracture  was  not  recognized  until  fatal 
meningitis  had  occurred.  The  anterior  fossa  may  suffer  injury  by 
direct  violence  through  the  nose.  The  middle  fossa  of  the  base  of  the 
skull  is  more  often  broken  than  either  the  anterior  or  posterior,  though 
rarely  by  direct  violence.  The  break  is  generally  due  to  a  fissure 
which  extends  from  the  vault  through  the  root  of  the  zygoma  and  the 
petrous  portion  of  the  temporal  bone,  breaking  the  tympanum  and 
possibly  extending  to  the  basisphenoid.  The  cerebellar  fossa,  as  has 
been  already  said,  is  more  apt  to  be  broken  by  injury  done  to  the  back 
of  the  skull,  and  the  fissure  will  be  found  running  more  or  less  for- 
ward from  the  point  struck,  and  may  open  into  the  foramen  magnum. 

Prognosis  of  Skull-fracture. — There  is  generally  an  increasing 
mortality  in  fractures  of  the  cranium  from  before  backward,  the  least 
mortality  attending  fractures  in  the  front,  and  the  greatest  mortality  in 
the  occipital  region  ;  this  applies  both  to  the  vault  and  the  base.  Per- 
haps the  supposed  larger  mortality  in  the  occipital  region  may  arise 
from  the  fact  that  cases  escape  our  observation,  and  the  severe  wounds 
alone  are  recognized. 

Puncture  fractures  may  of  course  occur  anywhere,  and  are  char- 
acterized by  a  small  wound  both  in  the  soft  parts  and  in  the  cranium, 
perhaps  insignificant  in  appearance.  The  inner  table  of  the  skull  will 
be  broken  to  a  greater  extent  than  the  outer,  and  fragments  of  it  are 
apt  to  be  carried  into  the  brain.  Septic  matter  is  frequently  inoculated, 
so  that  operation  is  called  for.  In  gunshot  wound,  operation  is  not 
always  indicated.  The  anterior  fossa  of  the  skull,  as  well  as  the 
middle  fossa,  is  in  relation  with  cavities  by  which  inspection  becomes 
possible — namely,  the  nose,  the  orbit,  and  the  auditory  canal.  In 
suspected  fractures  of  the  anterior  fossa,  effusion  of  blood  is  very  apt 
to  travel  forward  in  the  sheath  of  the  optic  nerve  and  spread  out  over 
the  ball  of  the  eye,  making  its  appearance  as  a  subconjunctival  hema- 
toma. This  may  extend  up  to  the  cornea  and  obscure  the  sclerotic.  Sub- 
sequent to  this  hemorrhage  the  lids  or  intra-orbital  tissues  may  become 
edematous  and  discolored,  but  always  after  the  subconjunctival  effusion. 
Ordinary  "  black  eye  "  from  contusion  is  very  common,  but  here,  the 
lids  being  separated,  the  eye  will  be  found  normal.  If  fracture  should 
take  place  through  the  olfactory  plate,  much  blood  would  be  expected 
to  flow  from  the  nose ;  but  bleeding  from  the  nose  is  such  a  very  com- 
mon accident  after  head-injury  that  as  a  diagnostic  sign  it  carries  very 
little  weight.  Fracture  of  the  middle  fossa  of  the  skull  will  give  rise 
in  certain  cases  to  bleeding  from  the  ear.  Here  the  fracture  has  torn 
the  drum  of  the  ear,  and  has  extended  through  the  middle  ear  and  pe- 
trous portion  of  the  temporal  bone,  opening  the  subdural  space.  Under 
such  conditions,  the  flow  of  blood,  ceasing  in  twenty-four  to  thirty-six 
hours,  is  succeeded  by  a  flow  of  watery  fluid,  first  blood-stained,  then 
clear.     This   is   cerebrospinal   fluid,   and  is   highly  characteristic  of  a 


FRACTURES. 


8o3 


fracture  in  the  locality  stated.  In  one  or  two  cases  the  bleeding  has 
been  followed  by  a  limited  flow  of  water,  and  yet  subsequent  examina- 
tion has  not  shown  that  the  fracture  extended  into  the  subdural  space 
so  as  to  give  exit  to  cerebrospinal  fluid ;  here  it  is  believed  that  the 
fluid  poured  out  is  from  the  labyrinth.  It  is  a  surgical  curiosity,  and 
is  so  rare  that  a  flow  of  blood  from  the  ear  followed  by  watery  fluid 
may  be  taken  as  diagnostic  of  fracture  into  the  middle  fossa,  opening 
the  subdural  space.  The  apertures  through  which  the  cranial  nerves 
pass  may  be  involved  in  a  fracture,  and  the  implication  of  the  corre- 
sponding nerves,  with  disturbances  of  their  function,  will  assist  the 
surgeon  in  making  a  diagnosis.  Fractures  of  the  posterior  fossa  give 
no  external  evidence  of  bleeding,  but  one  may  sometimes  find  consider- 
able swelling  in  the  posterior  nares  or  pharynx. 

In  case  a  depressed  fracture  or  a  hemorrhage  involves  the  motor 
area,  valuable  information  as  to  its  extent  and  situation  may  be 
afforded. 

Healing  Skull-fracttires. — Fractures  of  the  skull  heal  with  little 
callus.  When  loss  of  bone  is  extensive,  the  hiatus  will  rarely  be  closed 
by  bone.  Strong  fibrous  tissue 
bridges  over  and  fills  up  the  open- 
ing, and  occasionally  contains 
small  fragments  of  bone.  This 
scar-tissue  may  be  so  firm  as  to 
give  to  the  examining  finger  a  sen- 
sation of  bone,  and  a  dissection 
ma)'  be  necessary  in  order  to 
recognize  the  material  with  which 
the  defect  is  closed.  Reimplanta- 
tion of  bone  after  fracture  with  loss 
of  bone  may  sometimes  close  a 
defect,  and  in  other  cases  necrosis 
after  a  certain  period  will  necessi- 
tate the  removal  of  the  implanted 
bone.  Repair  of  skull-fractures  is 
slow. 

The  Treatment  of  Skull- 
fracture. — A  depressed  fracture 
of  the  skull  (vertex)  which  is 
allowed  to  remain  unelevated  may 
give  rise  to  most  serious  symptoms 
— epilepsy,  etc. ;  and  since  clean 
operations  on  the  skull  are  fol- 
lowed by  a  minimum  of  risk,  it  is 
allowable  at  the  present  day,  in  a 
case  of  uncertainty,  to  incise  the  skull  over  the  supposed  fracture,  and 
by  sight  and  touch  recognize  the  condition  of  affairs  (Fig.  404).  This 
is  better  than  the  uncertainty  of  a  possible  depressed  bit  of  bone. 

For  elevation  of  depressed  bone  the  trephine  is  very  rarely  needed. 
The  sharp  corner  of  the  chisel  can  generally  be  inserted  between  some 
of  the  depressed  fragments,  and,  one  after  another,  they  can  be  raised 
into  position  or  removed.  It  is  essential  to  examine  carefully  the  under 
surface  of  depressed  fragments,  and  make  sure  that  all  the  loose  pieces 


Fig.  404. — Part  of  frontal  bone  and  nearly 
all  the  roof  of  the  orbit  removed  for  mental 
disturbance  following  depressed  fracture  one 
year  previously.     Complete  recovery. 


8o4 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


of  the  inner  table  have  been  removed.     The  dura  is  to  be  carefully 
examined,  and  repaired  by  suture  if  torn ;  and  where  there  is  any  doubt 


FlG.  405. —  Simple  depressed  fracture  of  the  skull  in  an  infant,  without  symptoms.     No  treat- 
ment.    Gradual  disappearance  of  depression  (Elliot's  case). 

on  the  subject,  broken  bone  had  better  be  removed  entirely  than  left 

with  a  possibility  of  setting  up 
future  trouble.  That  a  de- 
pressed fracture  will  necessarily 
kill  a  patient  if  let  alone  is  not 
true.  In  a  certain  number  of 
cases  epilepsy  develops  as  a 
result  of  such  pressure,  but  in 
some  others  absolutely  no  symp- 
toms are  recognized,  and  the  pa- 
tient leads  as  useful  and  as  long 
a  life  as  if  there  were  no  depres- 
sion whatever.  These  are  the 
exceptions  only,  and  the  occur- 
rence now  and  then  of  such  a 
case  is  to  be  looked  upon  as 
a  surgical  curiosity,  and  not  as 
an  index  to  treatment.  Rough 
edges  are  always  to  be  smoothed, 
and  then  the  scalp  closed  over  the 
seat  of  operation.  Arrest  of  hem- 
orrhage is  to  be  effected  by  liga- 
ture, and  the  scalp  closed  lightly 
and  not  tightly,  as  advised  under 
Treatment  of  Scalp-wounds. 
Fracture  of  the  base  is  unfor- 
tunately not  easily  got  at,  so  that  the  treatment  will  not  be  so  direct  and 


■ 

'  «/ 

"'■ 

•- 

hpr 

■    * 

' 

. 

1 

Ire 

« 

k 

Fig.  406. — Loss  of  bone  (traumatic)  3  by  4  inches. 


FRACTURES. 


805 


cleanly  as  where  the  vertex  has  suffered  injury.  Unquestionably,  many 
cases  of  fracture  of  the  base  recover,  but  the  prognosis  is  always  grave, 
especially  where  the  injury  occurs  by  means  of  a  wound  in  relation  to  the 
air.  This  is  the  case  when  the  tympanum  and  temporal  bone  are  fract- 
ured and  torn,  as  shown  by  the  flow  of  blood  and  cerebrospinal  fluid. 
Here  it  is  manifestly  impossible  to  get  at  and  clean  the  vicinity  of  the  fract- 
ure. Likewise,  where  the  base  of  the  anterior  fossae  is  opened  and  the 
nares  put  in  communication  with  the  interior  of  the  skull,  the  difficulty  of 
cleansing  is  at  once  apparent.  When  the  posterior  fossae  suffer  fract- 
ure, as  there  is  no  opening  normally  existing  through  the  skin,  much 
doubt  must  exist  in  regard  to  the  condition  of  affairs  present.  In  either 
case  cleanliness,  when  obtainable,  should  be  exercised.  Absolute  rest 
in  a  recumbent  posture  is  to  be  enjoined,  a  darkened  room  and  absolute 
quiet  insisted  on,  while  a  light  and  very  abstemious  diet  is  to  be  given, 
and  a  purgative  administered  daily. 

The  treatment  directed  elsewhere  in  this  article,  when  an  operation  for  the  removal  of  a 
head-tumor  is  undertaken,  is  the  treatment  to  be  carried  out  with  skull-fracture — the  same 
cleansing,  care  of  the  wound,  and  closure  of  the  wound  with  dressing. 

Gunshot  wounds  of  the  head  are  usually  penetrating  and  always 
compound,  and  are  serious  more  from  injury  of  the  bone  of  the 
meninges  than  of  the  brain  itself.  A  glancing  injury  from  a  bullet  is 
extremely  rare,  and  much  rarer  with  the  modern  projectiles  than  when 
a  more  slowly  moving  bullet  is  employed.     The  glancing  bullet,  sup- 


FlG.  407. —  a,  Gunshot  fracture,  showing  fissure;  i,  crush  of  the  skull;  comminuted  fragments 

wired  lightly. 


posing  that  such  a  thing  is  now  seen,  will  produce  a  contusion  of  the 
skull,  with  such  accidents  as  may  result  therefrom.  A  gunshot  wound 
of  the  skull  with  the  modern  army  weapon  produces  in  many  cases 
very  great  injury,  which  has  been  denominated  "  explosive  violence." 
A  bullet  passing  through  the  skull  will  produce  fractures  running  in 
every  direction,  as  though  great  violence  from  within  had  been  expended 
on  the  bones.  The  bullet  always  traverses  the  skull,  producing  two 
wounds ;  such  injuries  are  promptly  fatal.  The  explanation  given  is 
that  the  bullet,  in  its  very  rapid  passage  through  the  semi-solid  con- 
tents of  the  skull,  expends  its  force  on  that  mass  in  every  direction. 
There  is  not  time  enough  for  the  cerebrospinal  fluid  or  for  the  blood  to 
be  displaced  so  as  to  make  room  for  the  bullet,  so  a  rending  of  the 
cranium  takes  place.  This  has  been  experimentally  tried  and  verified 
by  vessels  filled  with  water,  even  although  the  top  may  not  have  been 


8o6  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

tightly  pressed  down.  Pistol-bullet  wounds  or  non-fatal  gunshot 
wounds  of  the  head  are  met  with.  I  [ere  the  bullet  does  not  travel  with 
as  much  velocity,  and  may  lodge.  The  injury  is  a  complex  one,  and 
will  always  be  complicated  by  a  forcing  into  the  brain  of  fragments  of 
skull.  The  symptoms  will  depend  upon  the  part  of  the  brain  injured, 
and  paralysis  of  some  portions  of  the  body,  extensive  bleeding,  or 
immediate  death  may  take  place.  Theoretically,  the  treatment  to  be 
followed  out  is  to  cleanse  thoroughly  the  field  of  injury,  to  place  the 
patient's  head  in  such  a  position  that  the  track  of  the  wound  shall  be 
vertical,  with  the  opening  above,  and  to  allow  a  probe  to  sink  by  its 
own  weight  through  the  brain-track,  and  if  the  bullet  have  struck  the 
opposite  side  of  the  skull,  to  trephine  there,  open  the  dura,  locate 
the  bullet,  and  extract  it,  leaving  the  trephine  wound  open  for  drainage. 
Practically,  very  few  cases  of  such  excellent  surgery  have  been  suc- 
cessful, while  by  conservative  methods  recovery  with  the  bullet  remain- 
ing in  the  brain  has  ensued.  In  case  it  should  be  deemed  unwise  to 
search  for  the  bullet  within  the  skull,  the  patient's  head  should  be 
placed  in  such  a  position  that  drainage  shall  take  place  outward  through 
the  opening  in  the  skull,  so  that  the  fragments  carried  into  the  brain 
may  make  their  way  out,  and  possibly  the  bullet  come  near  the  external 
opening,  so  as  to  permit  of  removal.  A  number  of  cases  are  on  record 
of  recovery  with  the  bullet  remaining  in  the  brain.  Where  the  bullet 
has  entered  the  skull,  apart  from  the  immediate  danger  from  the  injury, 
secondary  abscess-formation  is  to  be  feared.  Here  the  usual  symptoms 
of  brain-abscess  will  prevail. 

Generally  speaking,  then,  the  treatment  of  a  gunshot  wound  of  the 
brain  is  local  cleanliness,  first  and  most  important — shaving  the  scalp, 
etc.  Then,  if  the  fragments  of  bone  which  have  been  carried  into  the 
brain  do  not  present  at  the  opening,  or  if  the  bullet  do  not  present, 
unless  there  seem  to  be  special  indication,  it  will  be  unwise  to  trephine 
and  search  for  the  bullet.  The  probe  which  should  be  used  to  investi- 
gate the  track  of  the  bullet  through  the  brain  should  have  a  large  end 
and  be  sufficiently  long  to  pass  through  the  skull.  A  probe  with  a 
small  point  will  easily  penetrate  the  brain-substance  and  so  mislead  the 
surgeon.  An  aluminum  probe  or  a  Nelaton  probe  with  a  slender 
shank  is  best.  It  is  unwise  to  close  a  gunshot  wound  of  the  head. 
Before  attempting  to  remove  a  bullet  from  the  brain,  it  should  be  local- 
ized as  closely  as  possible  by  means  of  X-ray  photographs  taken  in 
two  or. more  directions,  so  as  to  give  the  point  by  means  of  intersecting 
planes. 

INJURIES  AND  DISEASES  OF  THE  BRAIN. 

Hemorrhage  may  be  extradural,  subdural,  or  central.  Extradural 
hemorrhage  is  usually  the  result  of  a  rupture  of  one  of  the  middle 
meningeal  branches,  with  or  without  break  of  the  skull,  the  effusion  of 
blood  taking  place  between  the  bone  and  the  dura.  Subdural  hemor- 
rhage may  be  from  bleeding  into  the  pia  arachnoid,  in  which  case  it  is 
from  the  middle  meningeal  vessel,  or  it  may  be  upon  the  surface  of  the 
brain,  when  it  will  be  from  the  rupture  of  one  of  the  vessels  of  the  pia 
mater,  with  tear  of  the  arachnoid.     In  either  case  the  internal  capacity 


EYJ  CRIES  AND   DISEASES    OE   THE   BRAIN. 


807 


of  the  skull,  so  far  as  the  nervous  matter  goes,  is  diminished  by  the 
amount  of  blood  effused.  If  the  blood  be  poured  out  quickly,  symp- 
toms of  interference  with  brain-function  will  soon  appear.  On  the 
other  hand,  where  the  hemorrhage  is  slow,  the  cerebrospinal  fluid  is 
slowly  pressed  from  the  cranium  into  the  spinal  canal,  and  symptoms 
of  brain-disturbance  appear  gradually.  When  the  effusion  is  between 
the  dura  and  the  skull,  the  necessary  stripping  off  of  the  dura  from  the 
skull  will  exercise  some  compression  upon  the  mouth  of  the  bleeding 
vessel.  If  the  clot  be  opposite  some  portion  of  the  brain  presiding 
over  motion  or  speech,  local  symptoms  peculiar  to  a  lack  of  function 
in  that  portion  of  the  brain  will  appear.  On  the  other  hand,  if  an 
effusion  of  blood  takes  place  into  the  subdural  space,  the  blood  will 
gravitate  to  the  base  of  the  skull  and  will  press  upon  the  basal  ganglia, 
so  that  general  rather  than  special  symptoms  of  compression  will  be 
apparent.  When  the  bleeding  is  under  the  pia  arachnoid,  due  prob- 
ably to  a  tear  in  one  of  the  veins,  it  takes  place  slowly,  the  effused 
blood,  spreading  out  in  a  more  or  less  thin  layer,  clots  on  the  surface 
of  the  brain  ;  it  dips  down  into  the  sulci,  and  may  give  rise  to  localized 
convulsions  from  irritation,  or  to  paralysis,  if  it  be  over  a.  motor  area. 
With  these  local  symptoms  the  general  symptoms  of  compression  will 
be  present.  These  local  symptoms  will  decidedly  assist  a  diagnosis. 
Irregularity  of  the  pupils  will  suggest  hemorrhage. 

Extradural  hemorrhage  is  almost  always  from  the  middle  meningeal 
vessel,  and  the  first  local  symptom  of  compression  will  probably  come 


XT, 


FlG.  408. —  Extradural  hemorrhage  from  rupture  of  the  middle  meningeal  artery  (from  fracture 

shown  in  Fig.  409). 


from  that  part  of  the  brain  lying  adjacent  to  this  artery.  Loss  of 
power  occurs  on  the  side  opposite  to  the  place  of  pressure.  There  is 
often  an  interval  between  the  infliction  of  violence  and  the  symptoms 
of  compression  due  to  intracranial   hemorrhage.     During  this  period 


8o8  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

intelligence  is  retained,  although  it  may  be  disordered.  This  is  the 
most  important  symptom.  The  following  sequence  of  events  is  pathog- 
nomonic and  calls  for  interference  at  once  :  Injury,  concussion,  recov- 
ery, a  period  of  intelligence  followed  by  hemiplegia,  somnolence,  un- 
consciousness, and  irregular  movements.  The  temperature  will  not  be 
elevated;  the  pulse  will  be  slow  and  full,  but  with  increasing  compression, 
may  become  rapid.  The  breathing  will  at  first  be  quiet.  Convulsions 
may  occur.  Later  the  breathing  becomes  stertorous,  and  some  rise 
of  temperature  takes  place.  Dilated  pupils  will  be  found  to  accom- 
pany the  late  stage  of  compression,  whereas  at  its  commencement  the 
pupil  is  contracted.  A  dilated  and  immovable  pupil  strongly  suggests 
a  local  compression.  If  trouble  be  limited  to  the  left  side,  aphasic 
symptoms  will  be  more  apt  to  occur  with  hemiplegia,  in  a  right-handed 
person.  In  the  right  side  hemiplegia  without  speech-disturbance  is 
usual.     Hemorrhage  may  cease  spontaneously,  but  the  pressure  on  the 


FlG.  409. — -Fissured  fracture  of  skull  crossing  the  middle  meningeal  artery.     The  hemorrhage 
resulting  from  this  fracture  is  shown  in  Fig.  408  (Elliot's  case). 

brain  will  continue  to  exist  until  the  clot  is  absorbed,  and  mental  dis- 
turbance will  persist  until  then.  A  clot  may  never  be  entirely  absorbed, 
and  may  cause  irritation  in  the  same  way  that  a  depressed  fragment  of 
bone  may  cause  Jacksonian  epilepsy. 

Injury  to  a  sinus  of  the  dura  may  happen  from  direct  trauma  and 
hemorrhage  may  occur,  or  the  bones  may  be  forced  in  upon  the  sinus 
and  the  hemorrhage  not  take  place  until  the  bone  is  elevated.  By 
pressure  with  gauze,  by  suture  with  fine  thread,  or  by  passing  a  liga- 
ture with  a  curved  needle  around  the  sinus,  it  may  be  arrested. 

Treatment  of  Intracranial  Hemorrhage. — The  treatment  already 
suggested  for  concussion  and  contusion  of  the  brain  will  be  proper  for 
intracranial  hemorrhage  until  a  diagnosis  is  made.  When  that  is  evi- 
dent, the  recumbent  posture  and  an  ice-cap  become  necessary,  together 
with  measures  to  reduce  the  force  of  the  heart-beat.  The  symptoms 
continuing,  it  is  a  question  whether  operative  interference  is  called  for. 
When  there  is  any  probability  that  the  effusion  is  due  to  a  rupture  of 


INJURIES  AND   DISEASES    OF   THE   BRAIN.  809 

the  middle  meningeal  artery,  the  skull  should  be  opened  without  hesi- 
tation, the  clot  removed  if  present,  and  the  bleeding  vessel  tied,  if  pos- 
sible. A  curved  needle  carrying  a  thread  is  passed  under  the  vessel 
proximal  to  the  wound.  The  opening  in  the  skull  should  be  large 
enough  to  permit  of  all  manipulation,  and  if  the  first  opening  is  not 
sufficient,  it  should  be  made  sufficiently  large  by  means  of  rongeur 
forceps.  Failure  to  find  the  clot  under  the  trephine-wound  may  occur, 
but  the  absence  of  pulsation  under  the  dura  and  the  discoloration  of 
the  dura  will  suggest  a  deeper  clot.  The  skull  having  been  largely 
opened,  the  dura  is  to  be  incised  a  sufficient  distance — \  inch — from 
the  edge  of  the  bone,  to  permit  of  sewing  up  afterward.  The  dura  then 
is  turned  down,  and  the  clot  evacuated  by  spoon  and  a  gentle  stream 
of  water,  the  bleeding  point  being  sought  for  and  tied.  If  the  hemor- 
rhage is  from  a  vein  of  the  pia,  it  will  be  found  with  much  difficulty. 

Hemorrhage  into  the  lateral  ventricle  presents  no  symptoms  dif- 
fering from  an  intracranial  hemorrhage  not  in  the  motor  region,  except 
greater  liability  to  convulsions. 

Hemorrhage  into  the  brain=substance  may  take  place  from  direct 
violence  with  fracture  and  depression,  and  will  be  subject  to  the  usual 
treatment  of  fracture  with  depression  ;  but  a  violent  contusion  of  the 
brain  without  fracture  may  occur,  and  the  contusion  may  be  sufficiently 
severe  to  give  rise  to  hemorrhage  into  the  brain-substance.  Such 
hemorrhage  is  usually  punctiform,  but  may  be  worthy  of  the  name  of 
extravasation,  if  the  amount  of  blood  poured  out  be  large.  In  such  a 
condition  of  affairs  there  would  be  present  the  violent  jar  of  the  pri- 
mary injury,  from  which  the  patient  might  recover,  and  then  would 
become  apparent  the  symptoms  resulting  from  the  extravasation  of  the 
blood  into  the  brain-substance.  If  compression-symptoms  were  pro- 
gressive, it  might  be  proper  to  open  the  head  and  attempt  to  find  the 
bleeding  point ;  but  the  operator  would  probably  be  unsuccessful.  If 
the  symptoms  are  not  progressive,  it  would  be  useless  to  open  the  head 
with  the  expectation  of  removing  the  clot;  more  harm  would  result  to 
the  brain  from  the  operative  measures  than  from  leaving  it  alone. 

Hernia  Cerebri. — This  name  is  given  to  a  protrusion  of  the  brain- 
substance  uncovered  by  membranes  through  an  opening  in  the  skull. 
It  occurs  after  fractures  or  wounds  with  loss  of  skull  in  which  the 
meninges  have  given  way  or  been  divided.  It  is  an  evidence  of  sepsis, 
local  perhaps.  The  protruding  mass,  which  is  brain-substance,  at  first 
is  small ;  it  subsequently  may  become  large,  may  slough,  may  suppu- 
rate, but  always  projects  above  the  level  of  the  skull.  It  will  pulsate 
and  is  soft  to  the  touch,  not  vascular,  however ;  it  is  possible  to  cut 
away  portions  of  the  hernia,  for  brain-substance  is  insensitive.  When 
portions  of  the  hernia  are  cut  away,  new  portions  are  apt  to  protrude 
through  the  skull.  As  inflammation  diminishes,  the  hernia  will  sink 
within  the  head  and  cicatrization  take  place,  or  the  patient  may  die  of 
general  sepsis  (Fig.  410). 

Treatment. — An  attempt  to  force  the  brain  back  into  the  skull  will 
give  rise  to  symptoms  of  compression  not  advantageous  to  the  patient. 
Cutting  off  pieces  of  the  brain  down  to  the  level  of  the  skull  is  not 
called  for.  A  clean  dressing,  with  a  light  compressing  bandage  to 
hold  the  dressings  in  place,  and  so  exercise  a  very  slight  pressure  on 


8io 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


the  hernia,  is  all  that  is  necessary.  The  surface  of  the  hernia  may 
slough,  and  if  so,  the  dressing  should  be  changed  and  cleanliness  con- 
tinued. As  the  wound  becomes  clean  and  cicatrization  takes  place, 
the  hernia  will  disappear. 


Fig.  410. — Hernia  cerebri. 

Brain-compression. — The  amount  of  compression  to  which  the 
brain  may  be  subjected  will  vary  with  the  rapidity  with  which  the  com- 
pression is  effected ;  and  this  may  be  explained  by  the  escape  of  cere- 
brospinal fluid  from  within  the  head  into  the  spinal  canal,  thus  permit- 
ting a  foreign  substance  to  occupy  space  within  the  cranium  without 
causing  pressure  on  much  of  the  brain-substance.  To  produce  this 
change  compression  must  be  effected  very  slowly.  A  rapid  compres- 
sion will  give  rise  to  local  effects  at  once.  Probably  from  3  to  6  per 
cent.,  or  thereabout,  of  the  intracranial  area  can  be  taken  up  by  a 
foreign  substance  without  the  symptoms  of  compression  becoming 
marked.  After  the  above  maximum,  however,  has  been  passed,  press- 
ure-symptoms may  be  expected.  It  is  on  account  of  this  that  extrav- 
asation of  blood  may  go  on  from  a  ruptured  vessel,  if  the  rupture  be 
small,  for  a  certain  time,  without  giving  rise  to  symptoms ;  or  the 
growth  of  an  intracranial  tumor  may  take  place  and  attain  a  decided 
size  without  giving  rise  to  symptoms  whereby  its  presence  would  be 
noted.  It  may  be  that  where  an  abscess  forms  in  the  brain,  the  press- 
ure-symptoms are  not  noticed  at  first.  The  primary  symptom  may 
be  one  which  results  from  the  involvement  of  some  specific  brain-area 
— for  instance,  in  the  motor  region.  Inasmuch  as  the  escape  of  cere- 
brospinal fluid  from  the  head  relieves  compression,  for  a  certain  time, 
at  all  events,  it  is  evident  that  an  excess  of  pressure,  if  such  increase 
take  place  slowly,  may  happen  without  disturbing  the  brain-function, 
as  is  frequently  the  case  in   hydrocephalus. 

The  symptoms  of  compression  are  mental  disturbance — which  may 
be  sensory  or  motor — irregular  movements,  vomiting,  and  progressive 
loss  of  consciousness,  running  into  coma,  with  snoring  when  sleeping, 
and  convulsions.  The  convulsions  may  be  more  marked  in  one  part 
of  the  body  than  in  another,  which  will  give  rise  to  a  well-grounded 


INJURIES  AND   DISEASES   OF   THE   BRAIN  8ll 

suspicion  as  to  the  locality  where  the  compressing  force  is  most  exer- 
cised. Breathing  and  pulse  are  both  slow  in  compression.  Optic 
neuritis,  if  compression  has  existed  a  certain  time,  will  be  found  ;  dis- 
turbance of  vision  also,  and  of  smell  and  taste.  Indeed,  all  the  cranial 
nerves  should  be  investigated,  and  while  in  general  compression  they 
may  tell  nothing,  yet  they  may  give  some  indication  in  the  early  stages 
of  a  compressing  growth. 

The  treatment  of  compression  is  naturally  to  take  away,  if  pos- 
sible, that  which  compresses. 

Open  Wound  and  laceration  of  the  Brain. — Laceration  of 
the  brain  occurs  under  very  many  circumstances  and  shows  very  many 
symptoms,  both  primary  and  secondary.  There  will  always  be  a  cer- 
tain amount  of  shock  as  a  primary  symptom,  and  there  will  be  very 
generally  a  certain  amount  of  infection  which  will  give  rise  to  inflamma- 
tion. The  portion  of  the  brain  which  is  lacerated  is  to  be  considered. 
As  a  rule,  a  wound  of  the  anterior  brain  gives  rise  to  much  less  mor- 
tality than  does  a  wound  of  the  posterior  part  of  the  brain,  while 
laceration  of  the  base  of  the  brain  is  the  most  promptly  fatal  of  all. 
Lacerations  of  the  brain  of  the  most  desperate  nature  have  been 
recovered  from,  while  fatal  symptoms  have  followed  a  very  minor  injury. 
Unless  a  portion  of  the  brain  essential  to  life  suffers  laceration,  it  is 
probable  that  infection  produces  the  fatal  result.  In  the  absence,  there- 
fore, of  infection,  laceration  of  the  brain  may  be  looked  at  not  so  very 
unfavorably.  It  is  practically  impossible  to  cleanse  the  lacerated  sur- 
face of  the  brain,  hence  the  absence  of  infection  is  an  accident  due  to 
the  cleanliness  of  the  vulnerating  instrument. 

The  part  of  the  brain  injured,  whether  in  the  motor  area,  the  area 
of  speech,  etc.,  will  have  to  do  with  the  symptoms  which  present.  A 
slightly  elevated  temperature  may  be  met  with,  but  not  always,  and  the 
pulse,  simply  from  the  laceration  of  the  brain,  does  not  seem  to  be 
changed  markedly.  After  forty-eight  hours,  when  inflammation  due  to 
infection  appears,  there  will  be  seen  the  symptoms  due  to  meningitis  ; 
the  temperature  will  be  high,  and  indeed  in  some  cases  will  be  found 
to  go  up  after  death.  Occasionally,  the  temperature  varies  on  the  two 
sides  of  the  body.  There  may  be  multiple  lesions  within  the  head, 
giving  rise  to  very  confusing  symptoms.  Inequality  of  the  pupils  is 
more  apt  to  be  due  to  the  hemorrhage  and  pressure.  Unconsciousness 
is  more  often  due  to  a  concussion  or  jarring  of  the  brain  than  to  lac- 
eration. The  mental  condition  after  laceration  of  the  brain  will  vary 
greatly  with  the  region  of  the  injury. 

Traumatic  Meningiti§. — Meningitis  is  an  evidence  of  infection. 
Acute  meningitis  is  an  infection  due  to  injury,  and  means  that  septic 
material  has  been  carried  to  the  meninges,  and  that  such  cleansing  as 
was  done  by  the  surgeon  was  insufficient  to  remove  the  inoculated 
sepsis.  From  this  as  a  primary  focus  the  disease  may  extend.  Prob- 
ably the  organism  which  gives  rise  to  the  inflammation  has  much  to  do 
— more  than  we  have  hitherto  suspected — with  the  course  of  the 
inflammation,  otherwise  it  is  difficult  to  know  how  meningitis  in  one 
case  is  circumscribed  and  promptly  followed  by  the  recovery  of  the 
patient,  while  in  another  case  the  patient  rapidly  dies,  with  all  the 
symptoms    of  constitutional  poisoning.     Meningitis  extending  to  the 


8l2  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

base  of  the  brain  is  extremely  fatal,  and  is  to  be  guarded  against  by 
immediate  and  thorough  cleansing  and  by  affording  drainage. 

Secondary  Meningitis. — Secondary  meningitis  by  extension  from 
the  seat  of  trauma  occurs,  indicating  that  during  convalescence  a  failure 
to  keep  the  wound  clean  has  occurred.  Veins  or  lymphatics  may  carry 
an  infected  clot  to  the  meninges,  or  the  clot  may  be  carried  by  direct 
continuity  of  tissue.  A  meningitis  commencing  from  an  injury  will  be 
most  pronounced  in  the  vicinity  of  that  injury;  but  when  once  inflam- 
mation has  taken  place,  there  will  be  cloudy  or  purulent  cerebrospinal 
fluid,  with  exudation.  Constitutional  sepsis  is  a  rapid  sequel  of  menin- 
gitis in  most  cases.  It  may  extend  not  only  to  the  base  of  the  brain, 
but  to  the  spinal  canal.  The  ordinary  clinical  symptoms  of  weak  and 
rapid  pulse,  elevated  and  variable  temperature,  delirium,  hyperesthesia 
of  the  surface,  restlessness,  retained  urine,  constipated  bowels,  intense 
headache,  glistening  eyes,  trembling  and  busy  hands,  followed  by  stupor, 
hebetude,  contracted  pupils,  which  often  do  not  react  to  light,  make  up 
a  picture  which  admits  of  little  doubt.  Should  meningitis  be  more 
pronounced  along  the  fissure  of  Rolando,  local  spasms  or  paralyses  are 
to  be  expected.  The  results  of  treatment  are  not  favorable.  Attention 
to  the  secretions,  rest,  removal  of  all  exciting  causes,  the  application 
of  an  ice-bag  to  the  head,  cool  sponging  if  the  temperature  be  high, 
strychnin  to  support  the  pulse,  will  probably  be  all  that  is  to  be  done. 
Whether  the  free  opening  of  the  skull  and  an  attempt  to  obtain  drain- 
age is  to  be  followed  by  good  results,  it  is  impossible  to  say ;  but  this 
much  is  certain,  that  when  inflammation  occurs  in  a  closed  cavity,  it  is 
always  important  to  have  that  cavity  opened,  so  that  the  products  of 
inflammation  may  find  an  exit  and  tension  be  relieved.  Where  a  fissure- 
fracture  has  traveled  to  the  base  of  the  skull,  basilar  meningitis  is  very  apt 
to  follow,  and,  inasmuch  as  many  important  cranial  nerves  are  given  off 
from  this  part  of  the  brain,  a  disturbance  of  their  function  will  be  noted. 
However,  the  inflammation  is  rarely  limited  to  the  base  of  the  skull,  but 
extends  to  the  upper  part  of  the  spine,  and  so  retraction  of  the  head  and 
interference  with  and  disturbance  of  the  upper  spinal  muscles  are  likely. 

Where  there  has  been  any  evidence  of  extension  to  the  spine, 
spinal  puncture  or  laminectomy  may  be  resorted  to,  with  irrigation  ; 
but  the  results,  up  to  the  present,  of  either  of  these  procedures  do  not 
hold  out  any  very  great  hopes. 

Sinus  thrombosis  is  believed  to  occur  most  often  in  middle  life, 
although  as  our  experience  increases  it  is  not  at  all  improbable  that 
both  childhood  and  old  age  will  be  found  to  be  subject  to  this  distress- 
ing condition.  It  is  the  result  of  infection,  and  while  occasionally 
following  traumatism,  is  more  often  seen  as  the  result  of  middle-ear 
disease.  The  lateral  sinus  is  usually  the  vessel  affected.  For  this 
subject  see  Vol.  II.  Chap.  XXVIII. 

iBrain-abscess. — It  is  proper  to  distinguish  acute  from  chronic 
abscess.  The  acute  form  succeeds  an  injury  and  gives  rise  to  the 
ordinary  symptoms  which  one  would  expect  from  an  abscess.  Evi- 
dences of  sepsis  are  always  present ;  high  pulse  and  temperature  exist. 
Abscess  of  the  brain  is,  of  course,  the  result  of  infection,  which  may  be 
carried  by  traumatism,  but  may  reach  its  situation  through  the  blood- 
vessels or  lymphatics,  as  in  other  parts  of  the  body.     Along  the  peri- 


INJURIES  AND   DISEASES   OF   THE   BRAIN.  813 

vascular  sheaths  infection  may  pass  to  the  place  where  we  find  the 
abscess.  Perhaps  in  this  latter  case  the  abscess  will  be  in  the  neigh- 
borhood of  the  ear — a  frequent  source  of  infection.  The  limiting 
membrane  of  a  cerebral  abscess  is  granulation-tissue.  The  pus  may 
be  thick,  and  may  be  variously  colored,  from  admixture  of  coloring 
matter  of  the  blood,  or  possibly  organisms  (pyocyaneus).  The  pus  is 
inodorous  if  thick  ;  if  thin,  it  is  apt  to  be  of  bad  odor.  If  a  vessel 
gives  way,  blood  will  be  poured  into  the  abscess-cavity.  Symptoms 
of  compression  will  scarcely  bear  an  exact  relation  to  the  size  of  the 
abscess.  Chronic  abscess  comes  on  very  insidiously  and  may  not  be 
diagnosticated  at  all.  The  onset  of  symptoms  is  slow  and  progressive, 
the  temperature  usually  subnormal,  while  the  pulse  gives  evidence  of 
compression  more  and  more  marked,  but  this  at  a  late  period,  not  at 
first.  Vomiting,  irregular  pulse,  and  irregular  chills  are  encountered ; 
but  the  last-named  symptom  will  be  seen  attended  by  disturbance  of 
temperature  to  the  extent  of  several  degrees  (Fahrenheit).  When  an 
abscess  makes  its  way  to  a  surface,  external  or  ventricular,  rupture 
and  a  fatal  meningitis  will  ensue.  The  prognosis  is  distinctly  bad, 
whether  acute  or  chronic  abscess  be  present. 

An  acute  abscess  of  traumatic  origin  will  present  symptoms  of  local 
sepsis,  as  mentioned  above,  sufficient  to  justify  a  decided  opinion  as  to 
its  presence  and  location.  A  chronic  abscess  will  often  tax  to  the 
utmost  a  surgeon's  knowledge  of  cerebral  topography  and  overtax  his 
power  of  localizing  the  disease.  Perhaps  of  all  symptoms,  pain,  more 
or  less  pronounced,  is  the  most  constant,  yet  it  is  referred  sometimes 
not  to  the  seat  of  disease,  but  to  some  other  portion  of  the  head ;  per- 
cussion will  increase  the  pain,  and  the  patient  will  regulate  his  move- 
ments so  as  to  avoid  jar  to  the  head  ;  sudden  change  of  attitude — e.g., 
rising  in  the  morning — may  bring  about  vomiting.  The  symptoms 
mentioned  will  increase  as  the  disease  progresses,  and  hebetude,  disin- 
clination to  make  effort,  and  stupor  will  be  added ;  yet  evidence  of 
motor  or  sensory  disturbance  of  the  brain  or  interference  with  the 
function  of  cerebral  nerves  is  needed  that  the  locus  of  disease  may  be 
discovered.  It  is  unnecessary  to  repeat  here  what  has  already  been 
said  in  regard  to  cerebral  localization. 

Treatment. — A  brain-abscess  after  localization  is  opened  by  making 
an  incision  of  sufficient  size  through  the  skull,  using  a  trephine  and 
enlarging  the  aperture  with  rongeur  forceps.  The  exposed  dura  is 
observed  for  pulsation,  change  of  color — necrosis — and  then  opened  as 
directed  in  the  section  on  Intracranial  Tumors.  Pial  vessels  can  be 
tied  between  two  ligatures  and  divided,  after  which  by  a  grooved  director 
the  brain  is  explored  and  the  abscess  opened.  A  pair  of  forceps  passed 
into  the  abscess  along  the  groove  of  the  director  will  enlarge  the  track 
for  discharge  of  matter.  The  abscess-cavity  is  to  be  cleansed  by  means 
of  the  curet  and  a  stream  of  sterile  normal  salt  solution,  and  then 
drained — by  tube,  if  deemed  expedient. 

Intracranial  Tumors. — Surgical  localization  and  clean  surgery 
have  rendered  possible  not  only  the  recognition,  but  also  the  removal 
of  tumors  within  the  head,  which  formerly  were  interesting  only  up  to 
the  point  of  diagnosis,  for  after  that  relief,  save  by  medical  means,  was 
not   to   be   expected.     Intracranial    tumors    present    for   consideration 


8 14  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

certain  questions  :  Whether  the  tumors  are  single  or  multiple,  whether 
they  are  individual  or  expressions  of  a  constitutional  condition,  whether 
they  are  primary  or  secondary,  whether  they  are  local,  circumscribed, 
and  capable  of  removal  in  their  entirety,  or  whether  they  are  diffused 
among  adjacent  structures  and  incapable  of  being  taken  away,  the 
portion  necessarily  left  continuing  to  grow.  Inasmuch  as  they  are  not 
subject  to  sight  and  touch,  stress  must  not  be  laid  on  their  characteristics. 
Age, — Starr's  Tables,  although  published  some  time  ago  (in  1893), 
do  not  differ  materially  from  our  knowledge  of  the  present  day.  Thus 
he  eives  : 


Tuberculous  cases  in 

childhood,  152  to 

41  in 

adults. 

Gliomatous  tumors 

37  " 

54 

" 

Sarcomatous    " 

34  " 

86 

" 

G 1  iosarcomatous 

5  " 

25 

" 

Cystic 

30  " 

2 

" 

Carcinomatous 

"               10  " 

33 

" 

Gummatous 

«                       2   «< 

20 

(< 

Not  stated 

30  " 

41 

t< 

Out  of  a  total  of  600 

3OO  " 

300 

" 

In  this  table  the  preponderance  of  tuberculous  tumors  in  childhood 
is  apparent.  Sarcoma  and  gliosarcoma  show  a  preponderance  for  the 
adult.  The  carcinoma,  as  would  be  expected,  is  more  common  in  the 
adult,  and  the  cyst  largely  among  children,  the  proportion  being  very 
great — 30  as  compared  with  2.  Equally  the  gumma  is  largely  in  excess 
in  the  adult.  A  large  number  of  cases  of  syphilitic  disease  of  the 
brain  from  an  infection  many  years  previous  improve  under  treatment 
and  recover ;  hence,  it  is  improbable  that  gumma  of  the  brain  is  more 
common  than  the  tables  show. 

Glioma  and  sarcoma  are  probably  not  to  be  differentiated  the  one 
from  the  other,  and  they  should  be  considered  together  in  their  symp- 
toms and  treatment.  They  are  usually  primary  in  the  brain.  As  a 
secondary  growth  of  the  vault  of  the  cranium  growing  inward,  I  have 
met  with  sarcoma  several  times,  but  secondary  to  a  primary  eye-growth 
sarcoma  is  not  very  infrequent.  Glioma  and  gliosarcoma  may  grow 
from  either  white  or  gray  matter,  and  are  more  often  diffuse  than  cir- 
cumscribed ;  and  when  I  say  diffuse  I  do  not  mean  infiltrated,  for  this 
they  undoubtedly  may  be,  but  I  mean  not  definitely  surrounded  by  a 
connective-tissue  capsule.  Probably  glioma  is  softer,  more  vascular, 
and  of  more  rapid  growth  than  sarcoma,  as  a  general  rule ;  but  in 
special  cases  the  reverse  may  hold.  Involvement  of  the  brain  may 
take  place  as  a  direct  extension  from  the  eye  back  from  within  the 
orbit,  the  primary  growth  being  in  nerve-tissue.  Sarcoma  of  the  bones 
of  the  skull  projecting  inward  may  occur,  but  such  cases  are  never  so 
difficult  of  diagnosis  as  when  the  tumor  starts  within  the  brain-sub- 
stance, and  this  is  so  for  two  reasons — first,  because  the  growth  may 
make  its  appearance  outside  the  bones  of  the  skull  and  so  be  recog- 
nized ;  and  secondly,  because,  by  growing  inward,  the  cortex  is  pressed 
upon  and  definite  symptoms  produced,  which  will  certainly  be  the  case  if 
the  motor  area  be  involved.  Of  the  cause  of  sarcoma  we  know  nothing. 
Injury  to  the  head,  as  in  other  parts  of  the  skeleton,  might  give  rise  to 
malignant  growth  ;  but  in  just  what  way  traumatism  should  be  applied 
so  as  to  injure  the  inside  of  the  head  seems  to  be  somewhat  indefinite. 


INJURIES  AND   DISEASES   OE   THE   &RAIN.  8 1 5 

Primary  carcinoma  of  the  brain  is  rare.  It  may  arrive  by  direct 
extension  from  an  epithelial  surface,  as  when  an  epithelioma  of  the 
scalp  perforates  the  skull,  or  it  may  appear  in  metastatic  form.  In  the 
latter  case  the  foci  may  be  multiple.  As  usual  with  carcinoma,  it  is 
more  apt  to  be  met  with  in  the  latter  half  of  life. 

Cysts  occur  with  complicating  malignant  growths,  as  the  result  of 
irritation  from  depressed  bone,  or  as  a  changed  condition  of  an  intra- 
cranial clot.  Cysts  may  be  due  to  parasites,  as  hydatid,  but  will  be 
very  rarely  encountered  in  this  country ;  they  are  of  slow  growth  and 
give  rise  to  no  symptoms  by  which  they  can  be  distinctly  differentiated. 

Tubercle  has  already  been  spoken  of  as  occurring  in  childhood  more 
often  than  in  adult  life,  and  it  is  a  question  which  presents  itself  whether 
the  growth  be  single  or  multiple.  Unquestionably,  in  many  cases  a 
tubercular  nodule  is  not  single.  A  primary  nodule  of  tubercle  must 
be  very  rare  in  the  brain  ;  it  may  be  secondary  to  a  growth  existing 
in  the  body,  yet  entirely  unknown  to  the  patient  and  incapable  of  being 
reached  by  the  surgeon.  It  is  scarcely  necessary  to  say  that  where 
the  presence  of  such  a  growth  is  in  question,  the  personal  and  family 
history  is  to  be  carefully  reviewed,  and  the  patient  examined  completely 
in  hopes  of  gaining  a  clew  in  regard  to  that  very  important  point — the 
expediency  of  an  operation.  The  prognosis  will  be  unfavorable  unless 
the  probability  of  multiple  growths  can  be  eliminated,  and  even  then 
the  uncertainty  attending  the  diagnosis  must  be  ever  present,  and  the 
prognosis  correspondingly  guarded. 

Gumma. — Here  local  evidence  of  previous  infection  is  to  be  sought 
for  by  an  examination  of  the  patient  stripped.  Previous  history  is  to  be 
investigated.  It  is  always  proper,  so  uncertain  is  the  diagnosis  of  intra- 
cranial tumors,  where  an  intracranial  tumor  appears  likely,  to  institute 
antisyphilitic  treatment,  which  should  be  pushed  rapidly  until  it  becomes 
apparent  that  no  favorable  result  is  to  be  expected  from  a  continuance 
of  such  treatment.  It  does  not  seem  reasonable  that  the  diagnosis  of 
gumma  is  to  be  accepted  because  of  temporary  improvement,  for  mer- 
cury may  act  as  a  good  general  tonic.  Temporary  improvement  has 
followed  the  institution  of  antisyphilitic  treatment  in  a  patient  suffering 
from  sarcoma  of  one  of  the  long  bones.  Hence  a  diagnosis  of  intra- 
cranial gumma  cannot  be  made  unless  the  patient  is  not  only  tempo- 
rarily but  decidedly  and  permanently  improved. 

The  Situation  of  Intracranial  Tumors. — They  occur  in  the  cere- 
bellum during  childhood  probably  twice  as  often  as  in  the  adult ;  on 
the  other  hand,  the  cortex  in  the  adult  is  the  seat  of  tumor  three  times 
to  once  in  the  child.  A  tumor  which  commences  in  the  base  of  the 
brain — the  basal  ganglia — in  the  internal  capsule,  can,  with  difficulty,  if 
at  all,  be  reached ;  indeed,  tumors  situated  here  are  usually  considered 
to  be  out  of  the  field  of  operation.  On  the  other  hand,  the  convexity 
and  sides  of  the  brain  are  open  to  operative  measures,  with  the  pros- 
pect of  affording  relief.  It  is  probable  that  6  per  cent,  of  brain-tumors 
are  removable.  Fibroid  of  the  dura  and  an  exostosis  from  the  cranial 
bones  are  distinctly  simple  tumors  producing  local  symptoms,  and  can 
be  subjected  to  operation  with  every  prospect  of  recovery ;  but  with 
the  other  tumors  mentioned  the  prognosis  is  always  grave.  The  geo- 
graphical diagnosis  will  rest  entirely  upon  the  localization  in  different 


8l6  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

portions  of  the  brain  of  certain  functions — as  has  already  been  stated — 
in  addition  to  which  the  interference  with  the  function  of  cranial  nerves 
must  be  taken  into  consideration.  With  a  tumor  in  the  frontal  region 
certain  mental  and  character  changes  are  to  be  expected.  The  patient 
will  experience  less  self-control,  become  more  irritable  than  usual,  and  his 
moral  nature  will  be  impaired.  Blindness  from  pressure  is  one  of  the 
later  symptoms,  and  may  be  expected  ;  optic  neuritis  is  frequent,  begin- 
ning on  the  side  where  the  growth  exists,  but  later  involving  both  eyes  ; 
vomiting  and  convulsions  occur.  Protrusion  of  the  eye  may  occur,  and 
this  without  direct  pressure  on  the  roof  of  the  orbit ;  probably  this  has 
to  do  with  interference  with  the  return  circulation  behind  the  orbit ;  I 
have  noticed  it  more  than  once.  Occasionally  there  will  be  local  con- 
gestion of  the  subconjunctival  vessels  or  eyelids.  In  the  parietal  region, 
in  the  neighborhood  of  the  fissure  of  Rolando,  there  will  be  inter- 
ference with  the  motor  tract,  and  a  tumor  commencing  here  will  give 
more  marked  symptoms  than  anywhere  else.  Aphasic  symptoms  vary 
with  the  fact  as  to  whether  the  patient  is  right-  or  left-handed,  the  cen- 
ter for  language  being  in  Broca's  convolution  ;  while  in  the  temporal 
lobe  auditory  aphasia  may  be  produced.  In  making  a  diagnosis  certain 
conditions,  characteristics,  and  growth  of  intracranial  tumors  deserve 
notice.  The  advent  of  symptoms  is  very  gradual,  and  according  as 
certain  areas  become  involved,  so  does  the  patient  develop  new  symp- 
toms, which  may  be  in  the  form  of  general  convulsions  or  local  spasms, 
paralysis,  awkward  motion,  or  interference  with  known  nerve-function  ; 
the  different  functions  of  which  the  patient  in  health  is  capable  must  be 
investigated  in  order  to  recognize  any  departure  from  the  normal.  A 
careful  study  being  given,  the  surgeon  will  still  be  in  doubt  in  no  incon- 
siderable number  of  cases.  Local  tenderness  on  percussion  over  the 
tumor  may  be  present ;  the  percussion  note  may  vary  on  the  two  sides 
of  the  head.  Attention  has  been  drawn  to  what  has  been  called  the 
cracked-pot  sound  on  percussion,  which  is  believed  to  be  due  to  loosen- 
ing of  the  sutures  ;  1  am  not  sure,  however,  that  any  very  decided  opin- 
ion can  be  drawn  from  it. 

Spasms  are  met  with  in  lesions  commencing  in  the  cortex — Jack- 
sonian  epilepsy — and  in  the  later  stages  of  other  growths  by  pressure 
involving  the  cortex.  A  gradual  extension  of  motor  symptoms,  accord- 
ing to  the  known  order  of  centers  about  the  Rolandic  fissure,  is  diag- 
nostic. As  pressure-symptoms  increase,  so  mental  effort  becomes  dis- 
tasteful to  the  patient,  and  hebetude,  dulness  of  thought,  and  a  change 
in  the  mental  characteristics  appear.  The  mind  becomes  more  and 
more  clouded,  and  the  patient  exhibits  disinclination  toward  mental 
activity ;  a  slow  and  full  pulse  is  to  be  expected.  Sight  and  hearing, 
taste  and  smell,  and  interference  with  speech  are  to  be  investigated,  and 
attention  paid  to  the  parts  of  the  brain  presiding  over  these  special 
senses.  Persistent  headache  in  one  locality  will  suggest  the  situation 
of  a  tumor.  Unconsciousness  or  vomiting  without  reason  is  rarely 
seen  without  marked  pressure-symptoms  ;  intracranial  nocturnal  pain 
is  suggestive  of  a  syphilitic  lesion.  Dizziness  may  be  complained  of  in 
stooping,  or  when  the  head  is  in  a  more  or  less  recumbent  position, 
suggesting  undue  vascularity  of  the  growth  or  surrounding  area,  which 
becomes  congested  when  the  head  is  held  downward.     Defective  articu- 


INJURIES  AND   DISEASES    OF   THE   BRAIN.  817 

lation  suggests  involvement  of  the  motor  nerve  of  the  tongue ;  numb- 
ness may  also  exist;  knee-jerk  and  ankle-clonus  are  to  be  investigated. 

Cerebellar  tumors  are  often  accompanied  by  headache ;  vomiting 
and  vertigo  are  met  with  in  a  certain  number  of  cases  ;  and  while 
general  convulsions  may  occur  from  tumors  anywhere  in  the  head,  in 
the  cerebellum  they  are  perhaps  more  often  met  with ;  nystagmus 
occurs.  A  staggering  gait  is  marked,  the  patient  staggering  usually  to 
one  side,  and  generally  from  the  side  upon  which  the  tumor  exists,  yet 
not  always.  Where  the  patient  exhibits  a  tendency  to  fall  directly 
backward,  the  middle  portion  of  the  cerebellum  is  apt  to  be  pressed 
upon.  Hemianopsia  may  be  present  when  a  cerebellar  tumor  exists. 
Retraction  of  the  head  may  occur ;  external  strabismus  suggests  a 
pressure  on  the  sixth  nerve  and  an  affection  of  the  eye  on  the  same 
side  as  the  tumor.     Optic  neuritis  exists   generally. 

Expediency  of  Operation. — When  the  question  of  operating  upon 
an  intracranial  tumor  presents  itself,  the  operator  must  ask  himself  sev- 
eral questions.  First,  Is  there  a  tumor  at  all  ?  second,  Where  is  it  ? 
Is  it  in  a  part  of  the  brain  accessible  to  surgery  ?  Is  the  tumor 
single  or  multiple  ?  Is  it  a  local  tumor,  or  is  it  but  the  expression  of 
a  constitutional  vice,  the  removal  of  which  will  not  cure  the  disease  ? 
Is  it  metastatic,  the  original  focus  being  elsewhere  ?  Is,  it  a  malignant 
tumor,  which  involves  more  brain  than  can  possibly  be  removed,  so 
that  a  portion  of  the  tumor  will  be  left  after  the  operation  to  grow 
again  ?  All  of  these  questions  should  be  answered  with  fair  accuracy 
before  an  operation  is  undertaken.  It  goes  without  saying  that  multiple 
growths  and  metastatic  growths  should  be  let  alone.  Tumors  incapable 
of  being  removed  should  be  let  alone.  A  tuberculous  tumor,  if  recog- 
nized, should  be  taken  away.  It  may  be  that  there  is  no  other  focus 
except  the  one  operated  upon — at  all  events,  the  patient  should  have 
the  benefit  of  the  doubt. 

Gummatous  Tumor  of  the  Brain. — Whether  or  not  such  a  tumor 
should  be  operated  upon  is  a  difficult  question,  because  of  the  diagnosis. 
If  antisyphilitic  treatment  in  large  doses  continued  for  some  time  does 
not  cause  absorption,  operation  should  be  attempted ;  but  from  the  fact 
that  treatment  was  not  efficacious  in  removing  the  growth,  the  operator 
would  probably  be  of  the  opinion  that  the  tumor  was  not  syphilitic. 
In  general  it  may  be  said  that  with  present  methods  of  opening  the 
head  the  removal  of  a  tumor  is  not  such  a  very  dangerous  thing ;  and 
inasmuch  as  the  outlook  without  an  operation  is  bound  to  be  fatal, 
much  risk  may  be  taken  by  the  operator  in  the  hope  of  doing  good ; 
so  where  the  diagnosis  is  reasonably  clear,  an  operation  should  be 
undertaken. 

Technic  of  Operating. — Very  few  operators  are  so  thoroughly  fa- 
miliar with  the  skull  and  the  brain  that  they  can  dispense  with  a  sawed 
skull  and  a  cast  of  the  brain  for  reference  during  an  operation.  The 
convolutions  of  the  brain  vary  in  different  people.  A  portion  only  of 
the  brain  is  exposed  to  view  during  operation,  and  it  is  not  always  pos- 
sible to  recognize  that  which  is  in  view.  By  means  of  a  battery  and 
proper  electrodes  it  is  possible  to  stimulate  the  motor  areas  and  produce 
definite  movements,  so  that  the  exposed  convolutions  can  be  recognized. 
The  entire  head  is  to  be  shaved,  and  any  evidence  of  previous  injury 


8l8  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

or  disease  carefully  noted.  The  usual  aseptic  precautions  having  been 
taken,  an  anesthetic  is  administered  and  the  operation  is  begun.  It  is 
a  good  plan  in  intracranial  operations  to  use  chloroform  as  an  anesthetic, 
for  congestion  of  the  brain  and  meninges  is  thereby  lessened.  The  two 
extremities  of  the  fissure  of  Rolando  are  to  be  located,  and  with  the 
burr  passed  through  a  small  incision  in  the  scalp  the  skull  is  marked, 
so  as  to  show  the  course  of  the  fissure  after  the  scalp  has  been  re- 
flected. This,  of  course,  is  done  only  where  it  is  necessary  to  reflect 
the  skin.  A  large  flap,  consisting  of  scalp  and  bone — osteocutaneous 
— is  to  be  turned  down,  so  as  to  expose  the  brain  where  desired.  The 
base  of  this  flap  is  directed  toward  its  blood-supply — the  temporal  or 
occipital  artery,  as  the  case  may  be — thus  assuring  its  vitality.  A  small 
flap  is  embarrassing  from  failure  to  expose  the  brain  sufficiently,  and  a 
large  flap  is  no  more  dangerous  than  a  small  one ;  so  the  flap  is  cut 
with  a  knife  down  to  the  bone,  the  bone  cut  and  forcibly  pressed  out- 
ward, so  as  to  give  way  at  its  base.  The  hemorrhage  is  to  be  arrested 
by  hemostats  or  ligatures  passed  with  a  curved  needle  under  the  skin. 
I  have  not  been  able,  by  encircling  the  head  with  an  elastic  band,  to 
arrest  bleeding  as  I  desired.  In  the  line  of  incision,  then,  the  bone  is 
to  be  cut,  and  here  the  operator  exercises  his  own  fancy.  I  prefer  the 
chisel,  others  prefer  to  trephine  and  cut  through  the  bone  with  proper 
forceps  or  the  electric  saw.  The  chisel  gives  good  satisfaction.  Several 
chisels  of  different  shapes  will  be  needed.  The  bone  having  been  cut 
through,  its  base  may  be  cut  somewhat  across  to  facilitate  breaking, 
then  the  whole  flap  turned  down.  Bleeding  from  the  bone  is  sometimes 
excessive  and  inconvenient.  It  usually  stops  with  a  little  pressure ;  if 
not,  the  edge  of  the  bone  at  the  bleeding  point  may  be  crushed  in  with 
heavy  forceps,  or  Horsley's  putty  can  be  rubbed  into  the  cut  edges. 
The  surface  of  the  dura  is  examined,  and  it  is  cut  ^  inch  from  the  di- 
vided bone  and  a  flap  turned  toward  its  vascular  base.  Any  bleeding 
points  are  tied  with  fine  silk.  If  the  tumor  present,  it  can  be  removed  ; 
if  it  should  not  present,  then  it  may  be  wise  to  enlarge  the  opening  in 
the  skull  with  rongeur  forceps,  so  as  to  expose  more  brain  ;  or  it  may 
be  that  the  tumor  is  covered  by  the  brain,  so  that  the  brain  will  have 
to  be  opened.  Palpation  will  enable  one  to  recognize  the  consistency 
of  the  brain,  and  also  probably  whether  there  is  a  tumor  under  the 
cortex.  It  is  better  to  make  a  cut  into  the  brain-substance  than  to 
puncture  it ;  the  latter  procedure  is  misleading,  for,  if  a  soft  tumor 
is  present,  it  may  be  of  the  same  consistency  as  the  brain,  so  that 
puncture  will  reveal  nothing.  It  is  well,  then,  to  incise  the  cerebral 
substance  and  investigate  with  the  fingers.  To  avoid  bleeding  from 
the  pia,  curved  needles  carrying  fine  silk  or  catgut  are  to  be  passed 
under  the  vessels  and  tied.  This  can  be  done  with  advantage  before 
an  attempt  is  made  to  remove  the  tumor,  in  order  to  prevent  hemor- 
rhage. The  consistency  of  the  tumor  will  determine  the  method  of  its 
removal ;  the  handle  of  a  knife,  or  the  finger,  the  handle  of  a  spoon, 
etc.,  may  be  used.  Hemorrhage  from  the  site  of  the  tumor,  if  excessive, 
is  to  be  arrested  by  ligature  or  gauze  pressure.  The  wound  is  closed 
by  putting  the  dura  back  in  position  and  stitching  it,  and  by  bringing  up 
the  osteocutaneous  flap  and  suturing  it  in  position.  The  bones  may  be 
united  by  suture,  or  it  may  be  that  suturing  the  scalp  in  place  will  hold 


INJURIES  AND  DISEASES   OF   THE  BRAIN.  8 1 9 

the  bone  ;  this  can  be  decided  at  the  time  of  operation.  I  think  it  wise 
that  in  most  cases  a  piece  of  gauze  should  be  left,  so  as  to  drain  any 
blood  which  would  otherwise  accumulate  in  the  bed  of  the  tumor,  and 
the  base  of  the  flap-bone  can  be  cut  away,  so  as  to  give  exit  to  the 
drain.  The  dura  is  stitched  with  fine  silk,  and  the  scalp  with  silkworm- 
gut,  but  the  suture-material  is  a  matter  of  no  importance.  At  the  end 
of  forty-eight  hours  I  remove  the  drain.  A  voluminous  dressing  com- 
pletes the  operation,  and  this  dressing  may  require  removal  if  the  flow 
of  cerebrospinal  fluid  be  very  great.  After  one  intracranial  operation 
the  flow  of  cerebrospinal  fluid  was  so  great  as  to  wet  through  three 
folded  sheets  in  the  first  twenty  hours. 

Protrusions  from  Within  the  Skull. — Protrusion  of  the  mem- 
branes from  within  the  skull  is  always  congenital,  and  is  called  meningo- 
cele. It  is  congenital,  and  more  often  seen  in  the  occipital  region  or 
in  the  neighborhood  of  the  orbit.  It  is  more  or  less  extensive,  and 
is  to  be  considered  as  essentially  of  the  same  nature  as  spina  bifida. 
Meningocele  will  present  in  a  line  of  normal  suture  or  where  there  is  a 
bone-defect.  If  the  protruding  membrane  contain  cerebral  tissue  only, 
the  tumor  is  a  meningo-encephalocele.  It  is  not  always  necessary  that 
such  a  tumor  should  be  seen  upon  the  surface  of  the  skull ;  it  may 
protrude  through  the  base,  and  is  found  in  the  nasopharyngeal  cavity. 
The  tumor  will  be  elastic,  will  fluctuate,  and  it  may  be  that  the  examin- 
ing hand  will  recognize  fluid  as  well  as  solid  contents.  They  are 
generally  partly — in  some  rare  cases  perhaps  entirely — reducible  within 
the  skull  by  pressure  ;  but  symptoms  indicating  brain-pressure  are  pro- 
duced when  such  a  tumor  has  been  made  to  disappear  entirely  within 
the  head.  Again,  such  actions  as  coughing,  sneezing,  crying,  which 
tend  to  produce  congestion  within  the  head,  will  always  produce 
increased  tension  in  the  protruding  tumor.  During  sleep  a  partial  sub- 
sidence of  the  tumor  is  noted,  as  well  as  a  diminished  tension.  Prog- 
nosis is  not  favorable,  few  such  children  living  beyond  a  very  short  time. 

Treatment. — Little  that  is  favorable  can  be  said.  Inasmuch  as  spina 
bifida  has  been  operated  on  of  late  years  by  excising  the  sac,  or  at  all 
events  much  of  it,  and  stitching  the  base  of  the  tumor,  a  similar  opera- 
tion may  be  tried  with  a  tumor  of  the  kind  under  consideration.  If  no 
brain-substance  be  in  the  sac,  a  more  favorable  prognosis  can  be  made  ; 
but  it  is  possible  that  the  tumor  can  be  reduced  and  the  sac  tied  off  or 
stitched  off  at  the  opening  of  the  skull,  and  then  the  aperture  in  the 
skull  closed  either  by  stitching  the  soft  parts  over  it  or  by  making  a 
covering  of  the  outer  table  of  the  skull  with  its  periosteum.  Pressure 
by  means  of  pads,  bandages,  etc.  does  not  seem  to  have  been  beneficial 
or  to  have  induced  a  cure  of  such  growths. 

Hydrocephalus. — A  term  applied  to  cases  in  which  fluid  collects 
in  the  ventricles,  distending  the  brain  and  head  (hydrocephalus  inter- 
mis).  The  condition  is  essentially  chronic,  may  be  congenital,  and  gen- 
erally occurs  during  childhood.  Influenced  by  the  collection  of  fluid 
in  the  ventricles,  the  brain  expands  and  sulci  are  obliterated.  With 
this  progressive  increase  in  bulk  of  the  brain  the  cranium  spreads, 
enlarges,  sutures  are  separated,  fontanels  elevated,  and  the  appearance 
with  which  one  is  familiar  is  established.  The  prognosis  is  distinctly 
grave.     In  the  early  stages  of  hydrocephalus  the  diagnosis  is  difficult, 


820  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

if  not  impossible.     When  the  skull  is  enlarged  and  takes  its  character- 
istic shape,  diagnosis  is  easy. 

Treatment. — For  medical  treatment  the  reader  is  referred  to  medical 
treatises.  Suffice  it  to  say  that  the  only  operative  treatment  that  offers 
possible  advantage  is  aspiration,  or  perhaps  drainage.  The  operation 
of  tapping  is  done  through  the  anterior  fontanel,  or  through  the  line 
of  a  suture  between  the  bones,  if  it  should  be  thought  best.  Strict 
attention  to  asepsis  is  absolutely  required.  Drainage  from  the  ventricle 
has  been  tried  by  a  number  of  surgeons,  but  it  is  not  an  operation  that 
can  be  generally  done  with  advantage  or  can  be  confidently  recom- 
mended. Withdrawal  of  fluid  from  the  spinal  canal,  and  therefore 
from  the  cerebral  ventricles,  can  be  easily  done  by  puncture  with  a 
fine  trocar  passed  between  the  laminae  in  the  lumbar  region.  As  a 
diagnostic  measure  it  offers  opportunity  to  investigate  the  cerebro- 
spinal fluid  and  the  organisms  therein,  but  scarcely  seems  to  be  a  ther- 
apeutic measure  by  which  excessive  secretion  of  this  fluid  shall  be 
prevented.  It  is,  however,  a  method  by  which  direct  application  of 
drugs  can  be  made  to  the  central  nervous  system. 

Aneurysm  within  the  Head. — Diagnosis  of  aneurysm  within 
the  head  is  extremely  difficult,  and  it  is  doubtful  if  certain  knowledge 
of  its  existence  can  always  be  obtained.  The  symptom  which  is  most 
relied  upon  is  the  aneurysmal  bruit ;  and  if  the  aneurysm  is  in  the 
neighborhood  of  the  eye,  protrusion  from  the  orbit  may  occur.  The 
presence  of  a  growth,  bony  or  otherwise,  which  diminishes  the  caliber 
of  the  artery  within  the  head  will  give  rise,  however,  to  a  similar  bruit 
to  that  upon  which  the  diagnosis  of  aneurysm  largely  rests.  Pressure 
upon  the  parent  vessel  without  the  head  will  cause  the  bruit  to  cease, 
but  this  will  be  the  case  whether  the  vessel  is  dilated  or  whether  an 
exostosis  exist.  The  patient  is  conscious  of  the  sound,  which  is 
extremely  disagreeable.  If  in  the  neighborhood  of  the  cavernous 
sinus,  the  blood-current  through  the  veins  will  be  interfered  with,  but 
this  is  as  true  of  an  exostosis  as  of  an  aneurysm.  A  malignant  growth 
pressing  on  the  vessel  would  give  rise  to  a  bruit,  but  here  the  increase 
of  symptoms  would  take  place  more  rapidly  than  if  an  aneurysm  were 
present.  The  only  treatment  that  offers  prospect  of  recovery  is  to 
tie  the  parent  vessel — usually  the  internal  carotid — and  this  it  will  be 
proper  to  do  on  the  affected  side,  if  the  symptoms  become  unbearable. 

TREPHINING. 

Trephining-  for  Imbecility. — If  imbecility  were  always  the 
result  of  a  known  condition  of  affairs  in  the  brain,  there  would  not  be 
much  difficulty  in  arriving  at  a  conclusion  as  to  whether  trephining  is 
beneficial  or  not ;  but  in  view  of  the  multiform  causes,  both  congenital 
and  acquired,  of  defective  intellect,  the  expediency  of  trephining  is 
most  uncertain.  Probably  the  most  sensible  way  to  look  at  it  is  to 
consider  that  imbecility  is  a  symptom,  and  then  to  discuss  the  question 
as  to  whether  trephining  will  relieve  it  by  removing  the  cause.  It  is 
perfectly  plain  that  when  an  undeveloped  brain  is  present,  trephining 
will  be  useless.  When  there  is  arrested  development,  no  good  is  to  be 
expected.     When  intracranial  tumors  or  clots  exist,  it  is  possible  that 


TREPHINING.  821 

some  benefit  may  result ;  but  the  cases  which  are  to  be  benefited  are 
those  in  which  there  is  some  definite  lesion  which  a  surgical  operation 
can  be  expected  to  remove.  If  the  imbecility  be  due  to  such  a  cause, 
in  removing  the  cause  the  trephining  will  benefit  the  condition  of  imbe- 
cility ;  but  without  this,  one  can  scarcely  expect  any  good  to  follow  an 
operation.  When  the  changes  are  in  the  brain-tissue,  as  from  an  excess 
of  connective  tissue  (porencephalus),  good  is  not  to  be  expected.  Of 
late  years  and  in  a  large  number  of  cases  the  scalp  has  been  reflected 
and  the  head  has  been  opened  veiy  extensively,  for  the  purpose  of 
permitting  an  increase  of  growth  and  development  of  the  brain.  These 
are  supposed  to  be  cases  in  which  the  brain  is  unduly  small.  A  favor- 
able result  has  been  reported  a  number  of  times  shortly  after  opera- 
tion, as  though  the  operation  had  acted  as  a  stimulant  to  the  develop- 
ment of  the  brain.  Probably  it  would  be  just  as  well  if  we  knew  the 
result  after  a  year  or  two,  then  we  might  form  an  idea  as  to  whether 
improvement  reported  immediately  after  operation  had  continued, 
and  whether  the  improvement  was  not  temporary,  or  whether  a 
relapse  to  the  original  mental  condition  did  not  take  place.  The  dura 
in  such  cases  has  never  been  opened  to  an  extent  equalling  the 
cranial  cut,  and  the  amount  of  enlargement  which  was  given  to  the 
intracranial  space  was  probably  not  very  great.  At  all  events,  before 
we  decide  as  to  the  expediency  of  such  an  operation,  some  light  on  the 
subject  is  wanted. 

Trephining  for  Epilepsy. — Trephining  for  epilepsy  is  one  of  the 
early  operations  of  which  we  have  record,  but,  having  been  often  unsuc- 
cessful because  performed  in  cases  not  suited  for  it,  it  was  done  more  and 
more  rarely.  At  the  present  time  it  is  employed  in  certain  cases  only, 
and  yet  still,  unfortunately,  it  yields  only  moderate  success.  The  cases 
in  which  trephining  produces  a  cure  are  those  to  which  attention  was 
called  by  Hughlings  Jackson — namely,  those  in  which  the  epilepsy  is 
the  result  of  a  definite  cortical  lesion,  and  the  epileptiform  convulsions 
become  general  only  after  having  given  indications  of  local  origin. 
Thus  there  will  be  an  indication,  sensory  perhaps,  but  more  likely 
motor,  of  some  special  region,  which  the  patient  will  appreciate;  after 
which  there  will  follow  indications  of  motor  disturbance  in  the  cortex 
of  the  brain  adjacent  to  that  in  which  the  trouble  has  commenced, 
and  then  by  extension  the  convulsions  become  general.  Thus 
there  may  be  disturbance  of  a  finger  or  the  thumb,  and  then  of  the 
hand,  wrist,  forearm,  arm,  etc.,  the  convulsion  always  commencing  in 
the  thumb,  and  spreading  thence.  In  such  a  case  it  would  be  proper 
to  open  the  skull  over  the  thumb-center,  which  might  be  found  dis- 
eased, either  from  adhesions  of  old  inflammation  or  from  a  cyst,  or 
a  tumor,  or  a  growth  of  some  kind.  It  would  then  be  proper  to 
remove  the  adhesion  or  the  growth,  or  even,  in  the  absence  of  any 
gross  lesion,  to  excise  the  center  presiding  over  the  portion  of  the  body 
first  affected,  in  the  expectation  of  removing  the  source  of  trouble.  In 
traumatic  cases  a  depression  of  bone,  or  a  loose  spicule  of  bone,  or 
adhesion  between  the  skull  and  the  brain — cicatricial  tissue — would  be 
a  cause  for  operation.  It  might  happen  after  an  injury  that  the  portion 
of  bone  plainly  depressed  did  not  correspond  with  the  center  from 
which  the  convulsion  started.     In  such  a  case  one  might  expect  to  find 


822  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

a  fragment  of  the  inner  table  pressing  on  the  brain,  or  a  blood-clot 
which  had  degenerated  and  become  cystic,  or  adhesion,  or  what  not; 
and  the  surgeon  should  always  be  guided  in  his  operation  by  the  study 
of  cerebral  localization  and  not  of  a  gross  depression  of  the  skull, 
which  he  would  easily  recognize.  It  is  perfectly  possible  for  a  depres- 
sion in  the  skull  to  remain  without  trouble  through  life.  The  indication 
for  an  operation  is  to  be  sought  for,  when  possible,  by  localizing  the 
offending  cause  in  some  known  cortical  area.  Operations  for  the  cure 
of  epilepsy,  when  of  the  Jacksonian  type,  are  to  be  looked  upon  favor- 
ably unless  the  epileptic  habit,  from  long  continuance,  has  become 
established.  In  that  case  the  prognosis  is  much  more  unfavorable. 
Shortly  after  the  beginning  of  the  trouble,  however,  trephining  may 
be  expected  to  have  a  good  result.  Where  the  lesion  cannot  be 
definitely  located,  where,  in  other  words,  the  cause  cannot  be  known, 
trephining  for  epilepsy  has  properly  fallen  into  disuse.  A  careful  study 
of  that  which  has  gone  before  in  regard  to  locating  lesions  in  the  brain 
is  to  be  considered,  and  the  operation  decided  on  or  not,  as  the  case  may 
indicate.  After  a  general  convulsion  local  paralysis  may  remain  ;  this 
is  believed  to  be  due  to  the  exhaustion  of  some  motor  center  in  the 
cortex,  and  will  probably  correspond  to  that  part  of  the  body  in  which 
the  convulsion  began.  If  so,  it  will  be  an  additional  aid  in  locating 
the  lesion.  This  will  be  true  if  the  centers  presiding  over  the  special 
senses — sight,  hearing,  and  speech — are  involved. 


CHAPTER    XXV. 
SURGERY   OF   THE   SPINE. 

SPRAIN. 

The  spinal  column  may  be  sprained  by  the  laceration  to  a  greater 
or  less  degree  of  its  ligaments,  the  result  usually  of  extreme  flexion,, 
though  violent  twists  and  overextension,  such  as  is  produced  by  fall- 
ing back  over  a  bar,  may  give  rise  to  the  same  form  of  injury.  The 
most  common  situations  for  sprains  are  the  cervical  and  dorsilum- 
bar  regions.  Probably  in  all  cases  some  tearing  of  neighboring  mus- 
cles and  fasciae  occurs,  leading  to  effusion  of  blood,  which  is  sometimes 
evidenced  by  a  swelling  or  by  discoloration  of  the  skin.  This  is  seen 
in  the  case  of  the  rider  who  is  thrown  over  his  horse's  head ;  the 
structures  attached  to  the  seventh  cervical  spine  are  torn  through,  and 
a  hematoma,  often  very  large,  makes  its  appearance.  In  severe  cases 
the  anterior  and  posterior  common  ligaments  may  be  lacerated.  Injury 
to  the  ligaments  which  are  in  close  proximity  to  the  spinal  canal  may 
be  associated  with  rupture  of  veins  and  hemorrhage  into  the  canal. 
Laceration  of  the  supraspinous  ligament  may  be  evident  on  examina- 
tion, but  with  this  exception  we  have  to  rely  for  diagnosis  rather  on 
the  subjective  symptoms  and  the  history  of  the  injury  than  on  any 
obvious  signs. 

The  symptoms  are  local  pain,  with  aggravation  on  movement, 
tenderness,  and  rigidity.  There  may  be  some  obvious  swelling  from 
extravasation  of  blood,  but,  owing  to  the  depth  of  the  parts  sprained, 
this  is  generally  absent.  When  the  injury  is  in  the  lumbar  region, 
there  may  be  inability  to  move  the  legs  or  to  start  the  acts  of  mictu- 
rition and  defecation,  owing  to  the  pain  that  the  necessary  muscular 
efforts  cause,  and  thus  a  lesion  of  the  cord  may  be  simulated.  Sprains 
may  be  associated  with  hemorrhage  into  the  canal,  or  complicated  by 
the  extension  of  inflammation  to  the  spinal  contents  when  the  struc- 
tures bordering  the  canal  are  affected.  Neuralgia  from  involvement  of 
the  nerve-roots  may  give  rise  to  long  persistent  trouble. 

Treatment  by  rest  and  hot  fomentations  is  the  first  essential.  If, 
however,  rest  is  prolonged  unduly,  muscular  and  fascial  stiffness  with 
accompanying  pain  will  result,  as  in  sprains  elsewhere.  It  is  well  to 
avoid  this  in  these  cases  by  the  early  adoption  of  massage,  and  espe- 
cially since  the  patient  is  likely  to  attach  an  exaggerated  importance  to 
his  spinal  pain. 

DISLOCATION. 

Dislocation  of  the  spine  apart  from  fracture  is  rare,  and  is  practi- 
cally confined  to  the  cervical  spine,  occurring  most  frequently  in  the 
lower  half  of  this   region.       It  may  be  either  unilateral  or  bilateral. 

823 


824 


JXJEKXATIONAL    TEXT-BOOK   OF  SURGERY. 


The  dislocation  is  usually  brought  about  by  hyperflexion,  which  causes 
the  inferior  articular  processes  of  the  vertebra  above  to  slip  forward  and 

upward  on  the  superior  artic- 
ular processes  of  the  vertebra 
below.  This  is  rendered  pos- 
sible by  the  tearing  or  sepa- 
ration of  the  intervertebral  disk 
and  laceration  of  the  intervening 
ligaments.  The  displacement 
of  the  upper  part  of  the  spine 
is  almost  invariably  forward 
(Fig.  411).  Unilateral  disloca- 
tion is  sometimes  brought  about 
by  extreme  rotation  of  the  neck. 
When  this  occurs,  the  head  will 
be  turned  toward  the  opposite 
side  and  fixed  in  that  position, 
while  an  irregularity  in  the 
spines  and  in  the  transverse 
processes  will  be  obvious. 

Pressure  upon  the  nerves 
issuing  between  the  displaced 
vertebrse  gives  rise  to  periph- 
eral pain  and  numbness.  Vary- 
ing degrees  of  paralysis,  both 
of  motion  and  sensation,  up  to 
the  level  of  the  lesion  will  result 
from  compression  of  the  spinal 
cord,  and  will  depend  upon 
the  amount  of  injury  inflicted. 
When  the  dislocation  is  uni- 
lateral, the  cord  may  escape 
injury  or  the  damage  to  it  be  but  slight.  Lesser  degrees  of  dis- 
placement, not  amounting  to  actual  dislocation,  may  occur,  as  in 
one  case  which  came  under  our  notice,  where  laceration  of  liga- 
ments led  to  undue  mobility  in  the  lower  cervical  spine.  Three 
months  after  the  accident,  tingling  in  the  fingers  could  be  produced 
by  forcibly  exaggerating  the  normal  movements  of  this  part. 

The  prognosis  depends  upon  the  degree  of  damage  to  the  spinal 
cord  either  produced  directly  or  resulting  from  intraspinal  hemorrhage. 
Occipito=atloid  dislocation,  the  result  of  violence,  is  always  fatal, 
but  recoveries  after  dislocation  of  the  atlo=axoid  articulation  are  on 
record.  If  after  an  injury  the  face  is  turned  to  one  side  and  the  power 
of  rotation  of  the  head  is  lost,  a  unilateral  dislocation  of  this  joint 
would  be  suspected.  If  the  transverse  ligament  is  torn,  or  the  odon- 
toid process  broken,  the  case  would  in  all  probability  be  at  once  fatal. 

Dorsal  dislocation,  if  it  ever  occurs,  could  not  be  diagnosed  from  a 
fracture-dislocation  at  the  same  spot. 

Treatment. — To  begin  with,  reduction  of  the  displacement  should 
be  attempted.  This  is  much  more  likely  to  succeed  when  the  dislo- 
cation   is    unilateral    than    when    it   is   bilateral.     It  is   usually   recom- 


Wm                                                       1 

Xgf 

J 

■     '             ■ 

m  ■  *     M 

1                 ■■  1 '••'•.» 

FIG.  411. —  Dislocation  forward  of  the  sixth  cervi- 
cal vertebra  (Guy's  Hospital  Museum). 


FRACTURE;   FRACTURE-DISLOCATION.  825 

mended  that  the  reduction  should  be  effected  by  combining  extension 
with  rotation  of  the  head  from  side  to  side.  It  seems  probable,  as 
Walton  points  out,  that  it  is  rather  to  the  manipulation  involved  in  the 
rotation  than  to  the  extension  that  the  success  of  this  procedure  is  to 
be  ascribed.  He  advocates,  therefore,  in  cases  of  unilateral  dislocation, 
the  use  of  retrolateral  flexion — that  is,  bending  of  the  head  obliquely- 
backward  and  to  the  side  opposite  to  that  of  the  displaced  process,  in 
combination  with  rotation.  He  found  experimentally  that  a  moderate 
amount  of  traction  in  a  direct  line  would  not  raise  the  displaced  artic- 
ular process  in  the  least  degree,  whilst  the  above  manipulation  readily 
unlocked  it. 

In  bilateral  dislocation  he  recommends  that  the  same  method  should 
be  employed  alternately  on  the  two  sides.  Reduction  will,  however, 
often  be  found  impossible.  Taking  into  consideration  the  fact  that 
death  very  speedily  follows  this  displacement,  if  unreduced,  we  con- 
sider that  the  right  line  of  practice  to  pursue  is  to  cut  down  and  expose 
the  vertebrae  from  behind,  dividing  such  structures  as  interfere  with 
reduction,  and,  if  necessary,  removing  the  superior  articular  processes 
of  the  vertebra  below. 

FRACTURE;  FRACTURE-DISLOCATION. 

Fractures  of  the  spinal  column  may  be  conveniently  divided  into 
those  that  involve  the  neural  arch  and  its  processes,  and  those  that, 
passing  through  the  bodies,  interrupt  the  continuity  of  the  spinal  column. 
These  latter  are  usually  associated  with  more  or  less  displacement  of 
the  upper  part  of  the  spine  on  the  lower — a  condition  to  which  the  name 
fracture-dislocation  is  given. 

Fracture  of  the  Neural  Arch. — A  spinous  process  may  be  fract- 
ured by  direct  violence;  being  superficial,  the  injury  can  be  recognized 
by  the  ordinary  signs  of  fracture — pain,  mobility,  crepitus,  and  irregu- 
larity in  the  line  of  the  spines. 

One  or  both  lamince  may  be  fractured,  with  more  or  less  displace- 
ment. Though  this  accident  cannot  always  be  recognized  with  cer- 
tainty, a  diagnosis  may  be  effected  by  attention  to  the  following  points : 
A  history  of  direct  violence;  lateral  mobility  of  a  spinous  process;  one 
or  more  spines  out  of  the  normal  line  or  depressed  below  the  level  of 
those  above  and  below ;  rarely,  crepitus  on  manipulation  ;  and,  in  some 
cases,  symptoms  pointing  to  compression  of  the  cord. 

The  importance  of  diagnosing  correctly  this  form  of  accident,  more 
especially  when  associated  with  pressure  upon  the  cord,  depends  on  the 
fact  that  it  offers  more  opportunities  of  hopeful  surgical  interference 
than  are  found  in  fracture-dislocation. 

Fracture-dislocation. — Fractures  of  the  vertebral  bodies  involv- 
ing a  complete  separation  of  the  spinal  column  are  usually  attended  by 
displacement  of  the  upper  part  of  the  spine  on  the  lower.  Fracture- 
dislocation  is  most  common  in  the  more  flexible  portions  of  the  spine — 
i.  e.,  in  the  lower  cervical  and  the  dorsilumbar  regions.  It  results  most 
commonly  from  indirect  violence,  such  as  is  caused  by  falls  onto  the 
head  or  buttocks,  by  a  weight  falling  upon  the  shoulders,  or  by  catch- 
ing the  head  in  passing  under  an  arch.     Under  such  circumstances  the 


826  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

injury  is  caused  by  acute  flexion  of  the  spine.  One  or  perhaps  two 
vertebral  bodies  are  irregularly  fractured,  while,  the  arches  being  forci- 
bly separated,  either  dislocation  of  the  lateral  joints  takes  place,  or  the 
neural  arch  and  its  processes  are  fractured.  The  upper  segment  is 
usually  displaced  forward  and  downward  on  the  lower,  owing  to  the 
line  of  fracture  having  commonly  this  direction.  The  same  injury  may 
result  from  direct  violence,  such  as  falling  back  over  a  bar.  In  these 
cases  there  occurs  considerable  comminution  of  the  arches,  whilst  from 
the  overextension  produced  the  vertebrae  are  torn  apart,  in  some  cases 
at  the  junction  of  a  body  with  its  intervertebral  disk.     As  the  result  of 


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FlG.  412. — Fracture  of  the  first  lumbar  vertebra,  with  displacement  forward  of  the  upper  seg- 
ment of  the  spine  (Guy's  Hospital  Museum). 

the  dislocation  forward  of  the  upper  part  of  the  spine  on  the  lower,  the 
cord  is  more  or  less  severely  nipped  or  completely  crushed  from  the 
scissor-like  action  of  the  fragments. 

All  grades  of  severity  are  met  with,  but  the  extent  of  the  injury  has 
to  be  inferred  rather  from  the  history  of  the  accident  and  the  degree  of 
paraplegia  resulting,  than  from  a  local  examination  of  the  spine,  which 
may,  especially  in  muscular  patients,  show  but  little  deformity,  masked, 
too,  as  the  latter  is,  by  subcutaneous  blood-effusion. 

Symptoms. — There  is  generally  severe  local  pain,  and  the  patient 
has  a  marked  dread  of  movement.  He  may  volunteer  the  statement 
that  his  back  is  broken,  and   complain  of  loss  of  feeling  in  the  parts 


FRACTURE  ;    FRACTURE-DISL  OCA  TION. 


827 


below.  It  might  be  supposed  that  collapse  would  be  marked ;  but  this 
is  not  the  rule,  and  the  alertness  of  the  patient  might  suggest  to  the 
inexperienced  that  he  had  suffered  no  very  severe  accident. 

Locally  a  boss  may  sometimes  be  felt,  this  being  due  to  the  promi- 
nence of  the  vertebra  below  the  line  of  fracture,  consequent  on  the  for- 
ward displacement  of  the  upper  segment  of  the  spine;  or  there  may  be 
a  wide  separation  between  two  spinous  processes,  as  though  one  ver- 
tebra had  been  rent  from  the  other  by  hyperflexion.  A  spinous  process 
may  be  broken  off  at  its  base  or  through  the  neural  arch,  and  occasion- 
ally crepitus  is  felt  as  the  patient  is 
lifted.  Accompanying  the  bone-inj  u  ry 
will  be  much  bruising  and  laceration 
of  the  soft  parts,  with  swelling  from 
extravasated  blood,  which  renders  an 
examination  of  the  bones  beneath 
difficult. 

Injury  to  the  spinal  cord  is  the 
most  important  result  of  fracture-dis- 
location (Fig.  413),  and  its  severity  is 
to  be  judged  by  the  extent  and  sever- 
ity of  the  paraplegia.  Usually  this  is 
complete,  the  accident  being  followed 
by  entire  loss  of  movement  and  sen- 
sation in  the  parts  below  the  level  of 
the  lesion.  When  partial,  there  is 
some  hope  that  blood-extravasation 
and  not  bone-displacement  is  the 
cause  of  the  paralysis.  Where  the 
cord  has  been  divided  across,  the  im- 
mediate and  permanent  loss  of  the  knee 
and  deep  reflexes,  besides  complete 
paraplegia,  is  usually  seen.  The  super- 
ficial reflexes,  variable  in  health,  are 
unreliable  for  diagnosis.  The  bladder 
becomes  paralytically  distended,  over- 
flow incontinence  resulting.  The  rec- 
tum also  is  paralyzed.  In  partial 
transverse  lesion  of  the  cord  absence 
of  deep  reflexes  and  the  presence  of 
complete  paraplegia  will  at  first  be 
observed,  but  in  a  week,  more  or  less,  the  paraplegia  will  be  noticed 
to  be  incomplete,  exaggerated  reflexes  and  ankle-clonus  will  be  found, 
the  bladder  will  be  emptied  involuntarily  and  unconsciously,  and  the 
motions  will  be  spasmodically  passed.  In  these  latter  cases  improve- 
ment may  continue  for  a  time,  and  then  evidence  of  degeneration  of 
the  pyramidal  tracts  will  be  seen  in  increased  energy  of  the  reflexes 
and  the  onset  of  a  spastic  or  contractured  state  of  the  muscles.  This 
condition  is  not  seen  in  complete  transverse  cord-division,  though  some 
pyramidal  degeneration  be  present. 

After  the   immediate   effect  of  the   injury  is  over,  priapism,  partly 
from   paralytic   engorgement,  partly  from  reflex  irritation  (the  erection 


Fig.  413. — Fracture-dislocation,  show- 
ing crushing  of  the  cord  (Guy's  Hospital 
Museum). 


828  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

center  not  having  been  destroyed),  is  commonly  seen  ;  ejaculatio  sem- 
inis  is  less  frequent. 

Where  paraplegia  is  not  total,  sensation  will  predominate  over 
motion,  and  a  study  of  the  anesthetic  levels  is  the  safe  guide  to  the 
exact  physiological  level  of  the  cord  injury.  A  band  of  hyperesthesia 
at  the  limit  of  the  anesthetic  area  is  generally  present.  The  tempera- 
ture after  the  injury  is  usually  considerably  raised,  reaching  io6c  F.  or 
even  a  greater  height ;  later  it  becomes  subnormal,  though  it  may  be 
influenced  by  the  various  complications,  such  as  cystitis,  which  subse- 
quently arise. 

Serious  interference  with  breathing  is  caused  by  injury  to  the  cord  in 
the  cervical  and  dorsal  regions.  A  lesion  above  the  fourth  cervical 
nerve  will  cause  death  from  total  failure  of  respiration.  Below  this 
point  respiration  will  be  carried  out  by  the  diaphragm,  owing  to  the 
escape  of  the  phrenic  nerves,  and  by  a  varying  number  of  intercostal 
muscles,  depending  upon  the  level  of  the  injury.  In  the  lower  dorsal 
region  breathing  may  be  hampered  by  paralysis  of  the  abdominal 
muscles  and  by  tympanites.  When  the  injury  is  in  the  lower  cervical 
spine,  contraction  of  the  pupil  often  exists  from  damage  to  the  cilio- 
spinal  center. 

Prognosis. — This  is  always  exceedingly  grave,  not  only  as  regards 
immediate  risks  to  life,  but  from  the  point  of  view  of  subsequent 
recovery.  It  depends  on  the  degree  of  injury  to  the  cord  and  on  the 
situation.  The  higher  up  the  injury,  the  more  serious  the  case ;  and 
whilst  it  might  be  expected,  upon  physiological  grounds,  that  a  partial 
division  of  the  cord  offered  the  better  chance,  yet  clinically  there  is 
little  choice  between  the  spastic  palsy  of  such  a  case  and  the  total 
paresis  of  a  complete  section  of  the  spinal  marrow.  A  cord  com- 
pressed by  blood  or  by  a  depressed  neural  arch  or  a  fracture-disloca- 
tion in  the  lumbar  region  (area  of  chorda  equina)  offers  the  best  chance 
of  recovery,  more  or  less  complete.  Death  is  commonly  brought 
about  by  bronchitis  when  the  movements  of  the  chest  are  impeded  by 
bedsores,  cystitis,  and  suppurative  pyelonephritis. 

Operative  Treatment. — We  have  already  referred  to  the  fact 
that  fracture  of  the  neural  arch  is  more  likely  to  be  benefited  by  an 
operation  than  fracture-dislocation.  When  the  laminae  are  broken  by 
direct  violence  and  driven  in  on  to  the  cord,  the  case  may  be  compared, 
as  regards  treatment,  with  depressed  fracture  of  the  skull.  Lamin- 
ectomy should  be  performed,  and  the  depressed  fragments  elevated 
and  removed.  If  this  is  promptly  carried  out,  there  is  hope  of  com- 
plete relief,  though  the  large  amount  of  permanent  damage  that  a 
comparatively  slight  lesion  of  the  cord  may  cause  should  be  borne  in 
mind. 

When,  however,  we  have  to  deal  with  a  fracture  involving  the  con- 
tinuity of  the  spinal  column,  the  indications  are  less  clear.  Where 
marked  displacement  has  occurred,  and  no  doubt  exists  that  the  cord 
is  irremediably  crushed  by  the  scissor-like  action  of  the  two  segments 
of  the  spine,  operation  is  not  only  useless  but  harmful,  as  adding  to 
the  immediate  risks  of  life. 

Certain  cases  remain  in  which  the  paralysis  is  partial,  and  the  cord 
apparently  not  damaged  beyond  all  hope  of  repair.     It  happens  occa- 


FRA CTURE  ;   FRA  CTURE-DISL  OCA  TIOX.  8 29 

sionally  that  the  history  of  the  onset  and  the  character  of  the  symp- 
toms give  strong  reasons  for  supposing  that  the  paralysis  is  caused  not 
so  much  by  the  dislocation  of  the  spine  as  by  the  effusion  of  blood 
into  the  membranes,  or  more  rarely  by  a  spicule  of  bone  wounding 
the  cord.  Under  these  circumstances,  operation  for  the  relief  of  com- 
pression should  be  undertaken  without  delay.  Such  clear  indications 
are,  however,  rare,  and  more  often  it  is  impossible  to  state  the  exact  na- 
ture of  the  lesion  and  to  what  extent  the  cord  is  irremediably  injured. 
Two  courses  are  open  to  us — either  to  operate  in  every  instance 
of  doubt  or  not  to  operate  at  all  unless  some  clear  indication  for  so 
doing  appears  in  the  subsequent  course  of  the  case.  Of  the  two,  we 
prefer  the  former,  and  our  practice  is  to  perform  laminectomy  at  once, 
regarding  the  operation  in  the  first  instance  as  an  exploratory  one. 
The  hope  of  restoration  of  function  in  those  cases  in  which  the  cord 
is  not  irretrievably  damaged  depends  on  the  promptitude  with  which 
the  cause  of  compression  is  removed ;  and  however  small  the  number 
of  cases  may  be  in  which  benefit  is  to  be  looked  for,  we  hold  that  even 
these  few  justify  one  in  immediate  operation. 

It  is  not  difficult  to  perform  laminectomy,  since  the  soft  parts  are 
always  found  torn  and  detached  from  the  bone,  and  the  introduction 
of  cutting  instruments  or  forceps  under  the  laminae  is  easy  from  the  dis- 
placement present.  We  advise  the  thorough  irrigation  of  the  wound  after 
the  operation  and  its  immediate  closure  without  a  drain,  so  that  there 
may  be  no  need  of  the  frequent  dressings  that  drainage  would  entail. 

Where  an  exploratory  laminectomy  has  been  undertaken  in  fracture- 
dislocation,  and  such  displacement  found  that  the  removal  of  the  neural 
arch  does  not  suffice  to  relieve  pressure  on  the  cord  entirely,  the  oper- 
ation can  be  extended  to  the  lateral  processes,  so  that  manipulation  in 
the  wound,  combined  with  extension,  may  perhaps  succeed  in  restoring 
the  normal  line  of  the  spinal  column. 

Non-operative  Treatment. — This  begins  with  lifting  the  patient 
into  bed-,  and  requires  six  assistants,  two  below  and  two  above,  making 
extension  and  counterextension  by  the  legs  and  shoulders,  and  two, 
one  on  either  side,  with  hands  clasped  beneath  the  injured  back. 

When  the  first  slight  shock  is  over,  however  severe  the  case  may 
appear,  we  advise,  especially  in  dorsal  fracture-dislocation,  that  power- 
ful extension  and  counterextension  be  made,  aided  by  the  administra- 
tion of  an  anesthetic,  and  the  judicious  manipulation  of  the  spine  by 
the  surgeon  at  the  same  time.  No  harm  can  result  from  this,  and 
though  no  benefit  can  be  expected  in  those  cases  in  which  the  cord  has 
been  completely  crushed,  the  patient's  suffering  consequent  on  the  irri- 
tation of  nerve-roots  is  considerably  alleviated.  In  those  cases  in 
which  the  paralysis  is  only  partial,  and  in  which  reduction  is  preferred 
to  operation  as  a  means  of  treatment,  such  replacement  of  the  fractured 
vertebrae  may  be  an  important  factor  in  producing  some  amelioration 
of  the  paraplegia. 

Often,  however,  attempts  at  restoration  of  the  normal  line  of  the 
spinal  column  fail  from  impaction  and  interlocking  of  the  fragments 
of  bone. 

Rigid  confinement  in  the  supine  position  on  a  firm  mattress  must  be 
enforced  for  five  or  six  weeks,  when,  if  the  paraplegia  has  been  but 


83O  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

partial,  the  application  of  a  support,  such  as  a  poroplastic  or  plaster-of- 
Jr'aris  jacket,  will  enable  the  patient  to  sit  up,  and  shortly  to  be  out  of 
bed  on  crutches.  He  can  thus  be  induced  early  to  make  all  the  use 
possible  of  his  extremities,  while  at  the  same  time  his  own  efforts  are 
aided  by  massage  ;  and,  indeed,  we  advise  this  latter  in  partial  para- 
plegic cases  as  soon  as  the  patient  can  bear  the  manipulation. 

The  use  of  a  catheter  and  the  treatment  of  cystitis  will  be  guided 
entirely  by  the  surgeon's  experience.  Not  the  least  important  factor  in 
the  prolongation  of  the  patient's  life  is  careful  and  skilful  nursing,  the 
nurse's  special  aim  being  the  avoidance  of  bed-sores — a  difficult  matter, 
considering  that  the  feces  and  urine  are  always  passed  involuntarily. 

In  fracture  in  the  atlo-axoid  region,  if  the  patient  survive,  the  same 
care  must  be  taken  to  keep  the  head  rigidly  fixed  (whilst  the  patient  is 
recumbent  on  a  firm  bed)  within  the  curve  of  a  horseshoe  sand-bag,  a 
small  firm  pillow  being  placed  under  the  nape  of  the  neck.  After  a 
month  one  of  the  many  forms  of  instrumental  or  felt  supports  should 
be  fitted,  which,  by  fixing  the  head  and  supporting  its  weight,  will  allow 
the  patient  to  get  up  from  his  bed. 

Fracture  and  Dislocation  of  the  Coccyx.—  Dislocation  of  the 
coccyx  backward  may  occur  during  the  act  of  defecation  or  during 
parturition.  Displacement  forward  may  result  from  blows  or  falls  on 
the  buttocks,  though  under  these  circumstances  fracture  is  more  fre- 
quently produced.  Either  condition  can  be  easily  diagnosed  by  com- 
bined internal  and  external  examination  ;  and  reduction  being  effected 
by  the  fingers,  the  bowels  must  be  kept  confined  for  some  days,  the 
motions  being  subsequently  rendered  as  soft  as  possible  before  the  first 
action  takes  place. 

Both  these  forms  of  injury,  more  especially  fracture,  as  also  mere 
contusions  of  the  coccyx,  may  lead  to  a  severe  and  chronic  neuralgia 
known  as  coccydynia.  It  occurs  generally  in  women,  who  from  motives 
of  delicacy  will  frequently  refrain  from  mentioning  it,  and  adopt  semi- 
invalid  ways.  The  pain  is  often  so  severe  as  to  render  sitting  impossi- 
ble, and  any  movement  involving  a  strain  on  the  part  intensifies  the 
suffering.  The  pain,  though  chiefly  local,  may  extend  up  the  spine, 
and  in   nervous  people  give  rise  to  a  dread  of  spinal  disease. 

An  examination  may  reveal  nothing  but  a  tender  spot  on  one  or 
other  surface  or  at  the  tip  of  the  bone  ;  in  other  cases  evidence  of  dis- 
location or  fracture  may  be  found. 

Treatment. — When  nothing  to  account  for  the  pain  exists,  subcu- 
taneous division  of  the  structures  attached  to  the  bone  dorsally  and 
laterally  will  sometimes  produce  a  cure ;  but  if  not,  or  if  there  is  known 
to  be  vicious  union  after  fracture,  with  perhaps,  as  often  happens,  a 
painful  projecting  bony  spicule,  more  or  less  of  the  coccyx  should  be 
resected.  When  dislocated,  the  bone  may  be  replaced,  if  other  means 
fail,  by  resection  of  the  sacrococcygeal  joint,  aided  by  division  of  the 
surrounding  fascial  and  muscular  tissues. 

HEMATORACHIS  AND  HEMATOMYELIA. 

Hematorachis,  or  Spinal  Meningeal  Hemorrhage. — Hemor- 
rhage   into    the    membranes    may   accompany   injuries    of   the    spinal 


HEMATORACHIS  AND  HEMATOMYELIA.  83 1 

column,  or  may  be  the  sole  result  of  a  blow  or  fall.  The  blood  may- 
be extravasated  either  within  the  dura  mater  or  outside  it,  the  latter 
being  the  more  frequent. 

The  symptoms  indicative  of  hematorachis  are  severe  pain  in  the 
spine,  extending  some  distance  from  the  seat  of  injury,  and  dependent 
upon  irritation  of  the  meninges  ;  peripheral  pain  in  the  distribution  of 
the  nerves  which  have  their  origin  within  the  area  of  the  hemorrhage, 
due  to  the  irritation  of  the  sensory  roots  by  the  extravasated  blood, 
the  pain  being  paroxysmal  and  burning  in  character ;  muscular  spasm, 
or  occasionally  persistent  contraction,  frequently  associated  with  the 
latter,  produced  by  irritation  of  the  motor  nerve-roots,  and  having  a 
distribution  that  depends  on  the  particular  nerves  affected.  Opisthoto- 
nos may  result  from  involvement  of  the  vertebral  muscles,  and  occa- 
sionally a  general  convulsive  seizure  may  occur. 

Following  these  symptoms,  due  to  irritation  of  nerve-structures, 
paraplegia  of  varying  degrees  of  severity,  from  pressure  upon  the  cord, 
makes  its  appearance.  There  may  be  merely  slight  loss  of  power 
which  quickly  clears  up,  or  the  paralysis  may  be  severe,  though  it  is 
seldom  complete. 

The  prognosis,  unless  the  case  is  slight  from  the  commencement, 
or  amelioration  of  symptoms  commences  early,  is  unsatisfactory. 

The  treatment  to  commence  with  consists  of  absolute  rest,  the 
application  of  ice  to  the  spine,  free  purgation,  and  the  administration 
of  sedatives  when  the  pain  demands  it.  When,  however,  marked 
pressure-symptoms  exist,  or  when  improvement  does  not  show  itself 
early,  laminectomy  is  indicated.  We  do  not  see  any  reason  for  putting 
hematorachis  on  any  other  footing,  as  regards  operation,  than  that  on 
which  surgeons  have  always  placed  intracranial  meningeal  hemorrhage. 
Relief  can  be  afforded  in  most  cases  without  opening  the  theca,  as  the 
hemorrhage  is  generally  extradural ;  but  if  it  is  within  the  membranes, 
these  should  be  incised  and  blood  and  clot  washed  out. 

Traumatic  Hematomyelia. — Hemorrhage  into  the  substance  of 
the  cord  seems  confined,  as  the  result  of  injury,  to  the  region  of  the 
fourth,  fifth,  and  sixth  cervical  vertebrae,  our  experience  in  this  respect 
coinciding  with  Thorburn's.  The  latter  observer  attributes  this  lesion 
to  overflexion  of  the  spine,  the  usual  form  of  injury  to  the  lower  cervical 
region.  The  most  common  forms  of  accident  producing  such  acute 
flexion  and  consequent  hematomyelia  are  falls  and  blows  on  the  back 
of  the  head  and  neck,  or  forcible  bending  of  the  neck,  as  in  passing 
under  an  arch. 

The  blood-extravasation  is  usually  situated  centrally  in  the  gray 
matter,  and  varies  in  amount  from  small  punctate  hemorrhages  to  a 
collection  which  may  extend  from  1  to  2  inches  in  the  gray  substance. 
When  large  in  amount,  it  may  extend  into  the  white  matter,  or  even 
rupture  into  the  membranes.  It  produces  its  effects  either  by  destroy- 
ing or  compressing  nerve-tissue  (Thorburn).  As  the  result  of  destruc- 
tion of  gray  matter  in  the  lower  cervical  region,  paralysis  with  wasting 
of  muscles  and  anesthesia  occurs  in  the  upper  limb  and  in  the  muscles 
connecting  it  with  the  trunk.  When  the  effusion  is  large  enough  to 
cause  compression  of  the  white  columns,  paraplegia  varying  in  degree 
occurs  in  the  parts  below  the  level  of  the  lesion. 


832  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

When  the  cord  is  exposed  for  examination  in  fatal  cases,  the  hemor- 
rhage may  sometimes  be  seen  as  a  dark  swelling,  or  may  be  perceived 
by  the  finger  as  a  tense  bulging ;  in  other  cases  nothing  whatever  is 
obvious  externally. 

Symptoms. — Immediately  after  the  injury  the  case  may  appear  to 
be  one  of  total  transverse  lesion  from  the  completeness  of  the  para- 
plegia. The  paralysis  is  recovered  from  to  a  greater  or  less  extent  in 
the  lower  limbs,  leaving  perhaps  some  slight  weakness  and  rigidity  of 
the  legs,  and  is  then  practically  confined  to  the  upper  extremities. 
Here  more  or  less  loss  of  power  and  wasting,  depending  for  their  distri- 
bution upon  the  extent  of  damage  to  the  gray  matter,  remain  per- 
manently. When  the  effusion  of  blood  is  slighter  in  amount,  and  so 
produces  less  compression  of  the  white  columns,  the  paralysis  is  from 
the  first  mainly  localized  to  the  arms.  The  limited  injury  in  the  cord, 
causing  groups  of  muscles  to  become  paralyzed  about  the  shoulder- 
girdle  and  arm,  gives  rise  to  peculiar  positions  of  the  upper  extremity 
that  are  highly  characteristic. 

Occasionally  the  symptoms  increase  in  severity  for  some  hours  after 
the  injury,  owing  to  the  slow  escape  of  blood.  An  extension  of  the 
paralysis  at  a  later  period  will  be  due  to  myelitis.  Much  pain  is  com- 
plained of  locally  in  the  spine,  occasionally  shooting  down  the  arms  or 
around  the  chest.  A  rapid  rise  of  temperature  is  sometimes  seen,  reach- 
ing I02°-I04°  F.  within  forty-eight  hours  of  the  accident ;  and  extreme 
myosis  from  destruction  of  the  ciliospinal  center  may  also  be  present. 

The  prognosis  as  regards  life  in  severe  cases,  and  as  regards  ulti- 
mate recovery  in  all,  must  be  guarded.  Doubtless  many  of  the  less 
severe  cases,  which,  if  carefully  studied,  would  reveal  themselves  as 
cases  of  hematomyelia,  are  ascribed  to  spinal  concussion  and  sprain. 
While  recovery  from  the  results  of  compression  of  the  pyramidal  tracts 
may  be  rapid  and  complete,  there  is  usually  left  some  permanent  weak- 
ness, local  anesthesia,  and  wasting  in  the  upper  limbs. 

Treatment. — Beyond  rest  and  appropriate  medicinal  treatment,  there 
is  none  to  be  recommended.  The  punctate  character  of  the  hemor- 
rhage and  the  difficulty  of  determining  its  exact  position  in  many  cases 
when  the  cord  is  exposed,  and  the  fact  that  to  reach  it  would  inflict 
probably  even  greater  injury  on  the  nerve-tissues,  render  it  unlikely 
that  operation  can  ever  be  of  any  benefit. 

CONCUSSION. 

The  question  of  spinal  concussion  is  a  vexed  one.  While  some 
surgeons  practically  deny  its  existence,  others  class  under  that  name 
conditions  which  are  now  known  to  bear  a  different  interpretation. 
As  in  past  years  many  paraplegic  states  were  regarded  as  functional 
which  we  now,  with  improved  methods  of  investigation,  know  to  be 
the  result  of  definite  spinal  lesions,  so  the  generic  term  concussion  is 
gradually  becoming  more  and  more  limited  in  its  application.  By  "con- 
cussion of  the  spine  "  is  meant  a  more  or  less  complete  annihilation 
of  the  functions  of  the  spinal  cord,  immediately  consequent  upon  an 
injury,  temporary  in  character,  and  unattended  by  any  discoverable 
"toss  lesion. 


CONCUSSION.  833 

The  cases  that  have  generally  been  considered  as  due  to  concussion 
are  those  of  sprain  of  muscles  and  fasciae,  frequently  seen  in  railway 
cases,  the  so-called  "  railway-spine,"  in  which  no  cord-injury  at  all 
exists  ;  or  cases  of  hemorrhage  into  the  cord  and  membranes.  We 
can  only  speak  of  a  case  as  one  of  concussion  when  all  other  known 
causes  of  paraplegia  after  injury  have  been  excluded.  Even  then  the 
term  must  be  regarded  as  provisional,  for,  after  all,  the  idea  that  a 
molecular  disturbance  of  nerve-matter  constitutes  concussion  is  only 
a  good  working  hypothesis. 

The  a  priori  arguments  against  the  likelihood  of  spinal  concussion 
are  founded  upon  the  well-known  anatomical  relations  of  the  spinal 
cord ;  notably  its  small  size  as  compared  with  the  diameter  of  the 
spinal  canal,  and  the  way  it  is  suspended  with  lateral  support  from 
the  denticulate  ligaments  and  the  spinal  nerve-roots  themselves.  As, 
however,  we  know  that  hemorrhage,  the  result  of  an  injury,  may  take 
place  into  the  cord  without  any  obvious  lesion  of  the  spinal  column, 
there  need  be  no  difficulty  in  assuming  that  slighter  forms  of  injury 
may  lead  to  some  disturbance  of  the  cord  short  of  obvious  structural 
defects — that  is,  to  concussion. 

While  we  believe  spinal  concussion  to  be  rare,  we  see  no  other  way 
of  explaining  those  cases,  occasionally  met  with  in  the  accident-wards 
of  a  large  hospital,  which  after  a  fall  present  evidence  of  more  or  less 
paralysis  and  anesthesia  or  impairment  of  cord-function,  and  which 
within  a  week  or  less  have  complete  recovery  of  power  and  sensation. 
It  is  true  that  hemorrhage  into  the  spinal  cord  or  canal  might  possibly 
be  the  cause,  though  the  early  recovery  and  the  absence  of  character- 
istic symptoms  render  it  unlikely. 

In  hematomyelia  resulting  from  injury  the  hemorrhage  appears  to 
be  almost  invariably  confined  to  the  lower  cervical  region,  and  the 
destruction  of  gray  matter  causes  paralysis  of  certain  muscles  of  the 
upper  extremities,  while  the  legs,  which  generally  present  more  or 
less  paraplegia,  recover  much  more  rapidly  and  completely  than  the 
arms,  in  which  some  permanent  weakness  and  wasting  remains.  In 
hemorrhage  into  the  membranes  the  characteristic  symptoms  produced 
by  irritation  and  compression  of  nerve-structures  usually  suffice  to 
distinguish  these  cases  from  mere  concussion. 

In  concussion  the  arms  never  present  localized  paralyses,  such  as 
result  from  hemorrhage  into  the  cord ;  nor  do  we  ever  find  peripheral 
pain  or  muscular  cramp,  such  as  occurs  in  hematorachis.  In  view  of 
the  above  facts,  paralysis  picking  out  a  few  muscles,  or  spasm  or  pain 
in  the  distribution  of  certain  spinal  nerves,  must  be  held  to  exclude 
concussion. 

Symptoms. — A  very  few  cases  have  been  recorded  in  which  the 
paraplegia,  complete  from  the  first,  has  terminated  in  death.  Such 
cases  are  open  to  considerable  doubt  as  regards  the  diagnosis,  though 
we  are  unable  to  give  any  other  explanation  than  that  of  concussion  to 
the  case  we  describe  below.  Such  cases  would,  during  life,  be  almost 
certainly  diagnosed  as  hematomyelia  or  some  other  lesion  of  the  cord. 

The  more  characteristic  cases  present  incomplete  loss  of  power  and 
sensation,  the  paraplegia  being  usually  confined  to  the  legs,  though 
some  cases  may  also  have  some  weakness  of  the  arms,  most  noticeable 
53 


834  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

in  the  grasp.  Usually  the  bladder  and  rectum  are  also  reflected.  The 
loss  of  power  and  sensation  is  in  the  slighter  cases  most  marked  in  the 
feet  and  toes,  and  gradually  diminishes  as  the  trunk  is  approached. 
One  must  be  careful  not  to  mistake  for  concussion  those  cases  of 
sprained  spine  in  which  an  inability  to  move  the  legs  exists,  on  account 
of  the  pain  caused  by  such  attempts.  In  the  latter  cases  it  will  be 
found  that  this  supposed  paralysis  is  a  difficulty  in  raising  the  weight 
of  the  leg  from  the  bed,  movements  being  otherwise  unimpaired,  while 
in  the  former  such  inability  would  be  attended  with  paralysis  of  the 
whole  limb.  No  spasm  of  muscles  occurs,  nor  is  there  any  peripheral 
pain.  All  the  symptoms  pass  off  frequently  within  forty-eight  hours, 
or  at  latest  within  a  week. 

The  case  of  complete  paraplegia  referred  to  above  as  one  of  con- 
cussion was  under  the  care  of  one  of  the  writers  in  Guy's  Hospital  in  1894. 
A  woman  aged  fifty-nine  fell  down  stairs  on  to  her  back,  and  when 
picked  up  was  found  to  be  paraplegic.  No  special  investigation  of  the 
case  was  possible  for  some  hours.  It  was  then  noticed  that  there  was 
complete  loss  of  power  from  the  neck  downward,  with  paralysis  of  the 
bladder ;  the  breathing  was  carried  out  by  the  diaphragm.  At  first 
reflexes  could  be  obtained,  but  were  soon  lost.  There  was  anesthesia 
below  the  level  of  the  umbilicus.  On  the  second  day  the  temperature 
was  103.5  °  F«>  ar,d  on  the  tenth  she  died  from  pneumonia.  A  minute 
post-mortem  examination  was  made,  but  nothing  was  found  to  explain 
the  symptoms,  both  brain  and  cord  being  to  all  appearances  perfectly 
healthy.  But  for  the  autopsy  the  case  might  have  been  explained  as 
one  of  hemorrhage  into  the  cord  in  the  cervical  region. 

Treatment. — Beyond  rest  and  such  drugs  as  occasion  might 
suggest,  there  is  nothing  to  be  done. 

LAMINECTOMY. 

Laminectomy  is  the  operation  for  exposing  the  spinal  cord  and  its 
membranes  by  the  removal  of  more  or  less  of  the  neural  arches.  It 
is  indicated  when  pressure-symptoms  have  appeared  as  the  result  of 
compression  by  inflammatory  products,  blood,  bone-displacement,  and 
tumors  of  the  spinal  cord  and  membranes. 

As  usually  performed,  a  median  vertical  incision  is  made  through 
the  skin  over  the  affected  area ;  but,  as  has  elsewhere  been  pointed  out 
by  one  of  us,  it  is  far  better  to  make  a  bold  horseshoe  incision  so  as  to 
throw  an  integumentary  flap  either  upward  or  downward.  The 
advantage  is  that  there  is  no  surface-wound  over  the  spinous  proc- 
esses, since  the  curve  of  the  "  horseshoe  "  crosses  the  spine  between 
two  of  the  processes,  and  thus  neither  wound  nor  scar  is  pressed  on 
as  the  patient  lies  in  bed.  The  muscles  are  detached  by  a  vertical 
incision  on  each  side  of  the  spines,  and,  the  neural  arch  being  exposed, 
a  lamina  is  divided  by  a  Hey's  saw  or  by  cutting-forceps,  one  blade  of 
the  latter  being  inserted  beneath  its  lower  margin.  This  is  difficult  except 
in  those  cases  in  which  the  operation  is  undertaken  for  fracture,  and 
an  alternative  is  to  apply  a  large  trephine  on  the  neural  arch,  the  pin 
of  the  trephine  working  in  the  stump  of  a  spinous  process  which  has 
been  previously  cut  off.     By  this  means  a  part  of  the  lamina  of  each 


SPINA    BIFIDA.  835 

side,  with  the  root  of  the  spinous  process,  can  be  removed.  Further 
exposure  of  the  spinal  canal  is  readily  accomplished  by  means  of 
Hoffmann's  or  Horsley's  special  cutting-forceps.  The  theca  is  now 
exposed;  if  healthy,  it  will  have  over  it  a  variable  amount  of  fat  and 
large  veins  ;  but  in  cases  of  caries  of  the  spine  it  is  likely  to  present  a 
thickened,  leather-like  appearance,  with  chronic  inflammatory  deposits 
around  it.  On  incising  the  fat  over  the  dura  mater,  hemorrhage  from 
the  veins  in  it  may  for  the  moment  be  sharp,  but  is  controlled  by  press- 
ure. The  spinal  cord  is  now  exposed,  when  necessary,  by  a  vertical 
incision  through  the  dura  mater,  and  cerebrospinal  fluid  freely  escapes. 
Further  stages  in  the  operation  must  be  regulated  by  the  exigencies 
of  each  case.  The  dura  mater  should  only  be  opened  when  necessi- 
tated by  the  existence  of  the  lesion  within  the  membranes,  and  should 
especially  be  avoided  in  tuberculous  cases  on  account  of  the  risk  of 
setting  up  a  tuberculous  meningitis.  If  the  operation  has  been  merely 
exploratory,  and  nothing  abnormal  found,  the  wound  may  be  imme- 
diately sutured  without  any  provision  for  drainage ;  and  if  the  neural 
arch  has  been  removed  with  care,  more  especially  if  it  has  been  par- 
tially detached,  so  that  it  can  be  raised  as  on  a  hinge,  the  bones  also 
may  be  replaced.  When  an  infective  condition  is  met  with,  the  sur- 
geon's general  experience  must  guide  him  as  to  whether  to  leave  a 
drain  in  the  wound  or  not,  though  careful  cleansing  will  enable  him  to 
dispense  with  it  in  many  cases.  When  the  dura  mater  has  been 
incised,  drainage  of  the  subdural  space  should  be  effected,  when  found 
necessary,  by  a  capillary  drain,  such  as  horse-hair,  and  not  by  a  rubber 
tube. 

SPINA  BIFIDA. 

This  term  is  generally  used  to  denote  a  congenital  malformation  of 
the  vertebral  column  in  which  one  or  more  of  the  arches  have  failed  to 
close,  and  the  contents  of  the  spinal  canal  protrude  in  the  form  of  a 
fluid  tumor.  Not  all  forms  of  spina  bifida  are  included  in  this  defini- 
tion, for  in  some  cases,  though  the  laminae  are  deficient,  there  is  no 
protrusion. 

To  understand  the  nature  of  these  malformations,  the  development 
of  the  cord  must  be  borne  in  mind.  The  primitive  neural  canal  is 
formed  by  the  coalescence  along  the  median  line  of  the  medullary 
folds,  two  ridges  derived  from  the  epiblast.  In  this  way  a  hollow  tube 
is  formed,  which  eventually  becomes  separated  from  the  surface  epi- 
blast on  which  it  originated  by  the  ingrowth  of  mesoblast,  which  forms 
the  bones,  meninges,  and  muscles.  The  epiblastic  tube  thus  encircled 
is  the  spinal  cord. 

Varieties  of  Spina  Bifida. — These  may  be  grouped  under  five 
headings,  according  to  the  stage  at  which  arrest  in  development  takes 
place:  I.  Myelocele;  2.  Meningomyelocele;  3.  Syringomyelocele;  4. 
Meningocele;   5.  Spina  bifida  occulta. 

Myelocele. — In  this  malformation  the  medullary  folds  have  failed  to 
coalesce,  generally  to  a  limited  extent  at  the  caudal  extremity,  so  that 
the  central  canal  of  the  cord  opens  on  to  the  surface  of  the  body  in 
the  lumbar  region.  The  unclosed  portion  of  the  cord  is  represented  in 
the  lumbosacral  region  as  a  brieht-red  vascular  area  resembling  nevoid 


836 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


tissue.  In  a  specimen  in  Guy's  Hospital  Museum  this  area  is  of  a 
lozenge  shape.  It  usually  presents  a  median  longitudinal  furrow, 
which  represents  the  primitive  medullary  groove,  and  which  is  continu- 
ous above  with  the  central  canal  of  the  cord.  Microscopically  it  is 
found  to  be  composed  of  nerve-cells,  neuroglia,  and  nerve-fibers  inter- 
spersed with  a  plexus  of  arterioles,  venules,  and  capillaries  (Sutton). 
Arrest  of  development  or  asymmetry  of  the  spinal  column  is  often  asso- 
ciated with  myelocele,  and  ectopia  vesicae  often  co-exists. 

Meningomyelocele — In  this  variety  the  deficiency  in  the  arches  is 
associated  with  protrusion  of  the  spinal  cord  and  membranes.  The  sac- 
wall  is  composed  of  ill-developed  skin  and  dura  mater,  and  is  lined  by  the 

arachnoid  membrane,  its  cavity  being  con- 
tinuous with  the  subarachnoid  space.  The 
spinal  cord  leaves  the  canal  and  crosses  the 
sac  to  the  posterior  wall,  in  which  it  is  con- 
tinued as  a  flattened  layer  of  nerve-tissue 
still  retaining  its  central  canal.  From  this 
expansion  the  nerve-roots  arise  and  cross 
the  sac  to  their  respective  intervertebral 
foramina.  The  anterior  and  posterior  roots 
are  often  distinct  and  separated  by  a  con- 
tinuation of  the  ligamentum  denticulatum. 
It  is  the  most  common  variety  of  spina 
bifida,  forming  63.2  per  cent,  of  all  cases 
examined  by  the  Clinical  Society  of  London. 
This  form  is  due  to  a  failure  in  the  devel- 
opment and  ingrowth  of  the  mesoblast 
that  normally  separates  the  medullary  tube 
and  epiblast,  these  two  structures  conse- 
quently remaining  in  close  relationship. 
That  the  medullary  plates  have  coalesced 
is  shown  by  the  presence  of  a  central  canal 
in  the  flattened  cord. 

Syringomyelocele. — This  originates  in 
the  same  way  as  the  preceding  form,  from 
defective  ingrowth  of  mesoblast.  The  pro- 
.  trusion  contains  the  spinal  cord  and  mem- 
branes, but  the  cavity  of  the  sac  is  formed  by  the  dilatation  of  the 
central  canal  of  the  cord.  The  nerves  consequently  do  not  cross  the 
cavity,  but  pass  forward  to  the  foramina  round  the  outer  surface  of  the 
expanded  cord.  This  form  is  extremely  rare.  According  to  De  Ruy- 
ter,  it  is  invariably  situated  laterally.  Arrests  of  development  in  other 
parts,  such  as  ectopia  vesicse  and  genital  fissure,  are  common. 

Meningocele. — Here  the  membranes  alone  protrude,  the  cord  occu- 
pying its  normal  position  in  the  spinal  canal.  The  deficiency  in  the 
arches  is  usually  limited  to  a  small  extent.  Very  rarely  the  protrusion 
takes  place  between  two  adjacent  arches  or  from  the  hiatus  sacralis. 
The  cavity  is  lined  by  the  arachnoid  membrane.  Meningocele  has  a 
tendency  to  become  pedunculated,  and  in  some  cases  the  aperture  of 
communication  may  be  occluded.  According  to  the  Clinical  Society's 
Committee,  it  forms  8  per  cent,  of  all  cases. 


:.* 

1 

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1 

Fig.  414. — Spina  bifida  (menin- 
gomyelocele), showing  cord  and 
nerves  crossing  sac  (Guy's  Hospital 
Museum). 


SPINA   BIFIDA.  837 

Spina  Bifida  Occulta. — This  form  is  characterized  by  a  vertebral 
cleft  without  any  protrusion  of  cord  or  membranes.  Associated  usually 
with  this  malformation  is  an  abnormal  growth  of  hair,  which  may  be 
localized  over  the  defective  arches,  or  may  have  a  wider  distribution 
over  the  loins  and  buttocks.  This  hypertrichosis  may  exist  at  birth  01 
may  develop  at  puberty.  In  many  cases  this  is  the  only  symptom  of 
spina  bifida  occulta.  Attention  is,  however,  often  drawn  to  the  spinal 
malformation  by  the  presence  of  anesthesia,  club-foot,  perforating 
ulcers,  and  other  trophic  changes  of  the  lower  extremities.  These  are 
apparently  brought  about  by  pressure  from  local  hypertrophy  of  the 
cutaneous  and  subjacent  soft  parts.  In  the  limbs  examined  there  has 
been  found  a  thickening  of  the  vessel-walls,  especially  affecting  the 
muscular  layer,  and  also  in  some  cases  degenerative  changes  in  the 
nerves. 

Clinical  History. — Myelocele  is  incompatible  with  life  for  more 
than  a  few  days,  owing  to  the  continual  leakage  of  cerebrospinal  fluid. 

In  those  forms  (meningocele,  meningomyelocele,  syringomyelocele) 
in  which  the  cleft  is  associated  with  protrusion  of  the  spinal  contents, 
the  swelling  varies  in  size  at  birth  from  a  hazel-nut  to  a  small  orange. 
It  is  rounded  or  oval  in  shape,  occasionally  lobulated  from  the  presence 
of  septa,  and  generally  median  in  position,  though  it  may  deviate  a 
little  to  one  side.  As  a  rule  sessile,  with  a  slight  constriction  at  the 
base,  in  rare  cases  it  may  be  pedunculated.  Meningomyelocele  may 
present  a  median  longitudinal  furrow  corresponding  to  the  attachment 
of  the  cord,  or  a  dimple  (the  so-called  umbilicus)  at  the  summit  where 
the  cord  meets  the  sac- wall.  Both  dimple  and  furrow  are  by  no  means 
constant,  and  depend  to  some  extent  upon  the  distention  of  the  sac. 
In  consistence  the  tumor  is  sometimes  soft,  sometimes  firm  and  elastic, 
and  the  tension  is  increased  by  coughing  or  crying.  Fluctuation,  which 
is  always  obtainable  in  the  fluid  tumor,  may  be  obtained,  where  hydro- 
cephalus co-exists,  between  the  sac  and  the  fontanels.  The  deficiency 
in  the  arches  may  often  be  felt  when  the  sac  is  lax.  Normal  skin  but 
seldom  exists  over  the  whole  tumor;  in  most  instances  it  extends  up 
for  a  variable  distance  from  the  base,  the  rest  of  the  covering  being 
composed  of  a  thin  bluish  membranous  tissue.  It  is  not  uncommonly 
ulcerated,  or  even  gangrenous  on  the  surface,  and  in  some  cases  may 
present  patches  of  nevoid  tissue. 

Any  portion  of  the  spine  may  be  affected,  but  the  most  common 
situation  is  the  lumbosacral  region.  The  general  health  may  be  good 
and  the  functions  intact.  On  the  other  hand,  when  the  spinal  cord  is 
involved  there  may  be  paralysis  of  the  bladder,  rectum,  and  lower  limbs, 
and  associated  with  this  last-named  talipes,  most  commonly  calcaneus. 
Trophic  changes,  such  as  perforating  ulcer,  may  also  occur.  An 
important  complication  is  hydrocephalus.  This  may  be  present  at 
birth  or  may  develop  later,  and  in  a  few  cases  has  been  noted  as 
supervening  after  the  cure   of  the  spina  bifida  by  artificial  means. 

The  majority  of  cases  of  spina  bifida  die  if  left  to  themselves,  this 
being  due  in  a  large  proportion  of  cases  to  marasmus.  A  fatal  termi- 
nation may  result  from  rupture  of  the  sac  with  consequent  leakage  of 
the  cerebrospinal  fluid  ;  from  meningitis  following  inflammation  of  the 
sac ;  or  from  the  troubles  dependent  on  paralysis. 


838  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Diagnosis. — From  the  point  of  view  of  operative  interference,  it  is 
important  that  diagnosis  should  be  made,  if  possible,  between  meningo- 
cele and  meningomyelocele.  Attention  should  be  directed  to  the  fol- 
lowing points  distinguishing  meningomyelocele  :  I.  The  larger  size  of 
the  deficiency  in  the  arches;  2.  Umbilication  and  furrowing  of  the 
sac;  3.  The  presence  of  paralysis  and  club-foot.  Transparency  of 
the  sac  cannot  be  relied  upon  as  a  means  of  distinguishing  between 
the  two  forms,  for  some  sacs,  though  containing  cord  and  nerves,  are 
found  to  be  quite  translucent.  A  higher  situation  in  the  spine  or  the 
presence  of   a  pedicle  will  point  to  meningocele. 

Treatment. — In  those  cases  in  which  operative  measures  are  not 
justifiable,  treatment  will  be  limited  to  protecting  the  sac  from  injury. 
If  the  surface  is  ulcerated  or  gangrenous,  some  dry  antiseptic  dressing 
must  be  applied.  Parker  recommends  painting  with  iodoform  and 
collodion  in  cases  in  which  the  wall  is  very  thin.  Practically  the  only 
operative  measures  employed  are  the  injection  of  iodin  and  excision  of 
the  sac.  Treatment  by  repeated  tappings  is  but  seldom  resorted  to  on 
account  of  the  attendant  dangers,  while  ligature  of  the  base  must  be 
regarded  as  unjustifiable  from  the  impossibility  of  determining  with  cer- 
tainty the  absence  of  nervous  elements  in  the  sac. 

Injection  with  Iodin. — This  method,  which  aims  at  bringing  about 
a  cure  by  the  production  of  a  localized  adhesive  inflammation,  has  met 
with  a  considerable  amount  of  success.  Morton's  fluid,  which  is  used, 
consists  of  iodin  gr.  x,  potassium  iodid  gr.  xxx,  glycerin  sj.  The 
puncture  should  be  made  through  healthy  skin  at  the  base  of  the  tumor, 
to  avoid  risk  of  injury  to  the  spinal  cord  when  incorporated  with  the 
sac.  It  is  not  necessary  in  most  cases  to  withdraw  any  fluid  from  the 
sac  previous  to  injection.  From  J  to  2  drams  of  Morton's  fluid  are 
injected,  and  the  site  of  puncture  sealed  with  collodion.  The  cases  for 
treatment  should  be  carefully  selected.  Injection  should  be  postponed 
until  the  child  is  at  least  two  months  old,  unless  the  sac  is  threatening 
to  burst.  Paralysis  and  talipes  will  not  be  benefited  by  the  treatment, 
and  as  contraindications  may  be  mentioned  hydrocephalus  and  maras- 
mus. The  dangers  of  the  operation  are  shock,  convulsions,  meningitis, 
paralysis,  and  the  subsequent  appearance  of  hydrocephalus. 

Excision. — In  common  with  many  surgeons,  we  think  there  is  less 
risk  involved  in  incising  the  sac  than  in  injecting  it,  and  that  the  likeli- 
hood of  damaging  the  spinal  cord  and  nerves,  when  these  are  contained 
in  the  tumor,  is  less  in  the  former  mode  of  treatment.  The  contra- 
indications are  the  same  as  those  for  injection,  and  the  cases  should  be 
as  carefully  selected.  The  main  risk  of  this  operation  is  from  leakage 
of  the  cerebrospinal  fluid. 

Operation  (Mayo-Robson). — An  incision  is  made  through  the  skin 
on  each  side  of  the  tumor,  about  half  an  inch  from  the  base,  marking 
out  two  flaps,  which  are  carefully  dissected  off  the  meninges.  The 
membranes  are  then  punctured  to  let  out  the  fluid,  and  then  pared  away 
so  as  to  leave  two  flaps,  one  rather  longer  than  the  other  (f  inch  and  \ 
inch),  so  that  the  lines  of  union  of  the  meninges  and  skin-flaps  are  not 
superimposed.  The  pairs  of  flaps  are  then  sutured  separately  and 
closely  to  avoid  risk  of  leakage  of  the  cerebrospinal  fluid.  Where  skin- 
flaps   are   not   obtainable   from   the   base   of  the   tumor,  they  may  be 


CONGENITAL    SACROCOCCYGEAL    TUMORS.  839 

obtained  by  dissecting  up  the  skin  from  the  loins  sufficiently  to  allow 
of  the  flaps  being  slid  inward  toward  the  middle  line.  When  the  cord 
is  incorporated  with  the  sac,  a  careful  incisions  hould  be  made  into  the 
sac,  after  the  skin-flaps  have  been  fashioned,  to  determine  the  position 
of  the  cord  and  nerves.  Redundant  sac  should  then  be  cut  away,  care 
being  taken  not  to  injure  nerve-structures,  and,  the  cord  being  replaced 
in  the  spinal  canal,  the  meningeal  and  skin-flaps  are  closely  sutured 
over  it. 

CONGENITAL  SACROCOCCYGEAL   TUMORS. 

Parasitic  Tumors  (Teratomatat  originating  in  a  Duplica- 
tion of  the  Embryonic  Area. — These  may  be  regarded  as  the  lowest 
grade  of  a  series,  the  highest  expression  of  which  is  the  rare  malforma- 
tion known  as  "conjoined  twins."  They  occur  as  irregular  pendulous 
tumors  attached  to  the  coccygeal  region,  sometimes  of  large  size  at 
birth,  sometimes  increasing  in  size  subsequently,  and  bearing  no  resem- 
blance to  the  body  or  limbs  of  a  fetus.  They  differ  from  ordinary 
tumors  in  the  great  variety  of  tissues  of  which  they  are  composed.  In 
one  class  rudiments  of  the  skeleton  and  of  the  different  viscera  are 
found ;  in  another  the  tissues  present  nothing  suggestive  of  any  special 
organ.  While  the  former  are  to  be  regarded  as  remnants  of  a  parasitic 
fetus  which  has  failed  to  develop,  in  the  latter  there  is  some  doubt  as 
to  whether  the  tumor  is  to  be  considered  as  parasitic  or  as  due  to  a 
developmental  defect  in  a  single  individual. 

Cystic  Tumors  originating  between  Rectum  and  Sacrum. — 
The  majority  of  these  tumors  have  their  origin  in  persistent  remnants 
of  the  postanal  gut  and  neurenteric  canal.  They  may  be  either  multi- 
locular  or  unilocular.  The  former  give  rise  to  large  tumors,  often 
pedunculated.  They  are  made  up  of  a  number  of  cysts,  varying  in 
size  from  a  millet  seed  to  a  cherry,  which  are  lined  with  a  cylindrical, 
cuboid,  or  flattened  epithelium,  and  which  contain  a  thick,  mucoid  fluid. 

Unilocular  cysts  having  a  wall  similar  in  structure  to  that  of  the 
intestine,  and  found  lying  between  the  rectum  and  sacrum,  have  been 
met  with.  A  cyst  of  this  kind,  which  projected  into  the  rectum  as  a 
polypoid  tumor  the  size  of  a  hen's  egg,  has  been  described.  It  was 
readily  shelled  out  by  incising  the  rectal  wall  lying  over  it. 

Dermoids  also  occur  in  this  situation,  and  may  attain  a  very  large 
size,  one  weighing  as  much  as    14^   pounds   having  been   described. 

Cystic  Tumors  originating  outside  the  Sacrum  and  Coc- 
cyx.— Cysts  in  this  region  are  usually  sequestration  dermoids  arising 
along  the  line  of  coalescence  of  the  dorsal  folds.  The  possibility  of  a 
cystic  tumor  over  the  lower  end  of  the  sacrum  being  a  spina  bifida 
should  be  borne  in  mind.  Cases  of  meningocele  projecting  from  the 
hiatus  sacralis  as  a  pedunculated  tumor  have  been  reported. 

Allied  to  the  dermoids  are  the  dimples  and  sinuses  found  over  the 
coccygeal  region.  They  are  usually  regarded  as  resulting  from  imper- 
fect coalescence  of  the  dorsal  folds,  though  according  to  another  view 
they  are  vestiges  of  the  neural  canal.  The  sinuses  usually  open  oppo- 
site the  tip  of  the  coccyx,  and  run  upward  for  as  much  as  two  inches  in 
some  cases.  They  appear  to  be  lined  with  skin,  and  in  some  cases  hair 
is  found  growing  from  the  wall. 


84O  INTERNATIONAL    TEXT- BOOK   OE  SURGERY. 

ACUTE  OSTEOMYELITIS  OF  THE  VERTEBRAE. 

Acute  osteomyelitis  of  the  spinal  column,  though  rarely  met  with, 
derives  a  special  importance  from  the  close  proximity  and  liability  to 
infection  of  the  spinal  cord  and  membranes.  It  is  about  twice  as  fre- 
quent in  males  as  in  females,  and  though  liable  to  make  its  appearance 
any  time  during  the  period  of  growth  of  the  skeleton,  it  occurs  most 
often  between  the  ages  of  ten  and  fifteen.  The  disease  has  its  primary 
seat  in  the  lumbar  vertebrae  in  about  half  the  recorded  cases,  and  the 
initial  focus  of  inflammation  is  as  often  in  some  portion  of  the  neural 
arch  as  in  the  body.  Suppuration  occurs  in  every  case,  though  to  a 
varying  extent.  Tenderness  and  rigidity  of  the  affected  portion  of  the 
spine  are  the  first  symptoms,  followed  in  three  or  four  days,  in  those 
cases  in  which  the  arch  is  affected,  by  inflammatory  swelling.  When 
the  bodies  are  the  primary  seat,  the  abscess  will  form  in  front  of  the 
spinal  column  and  will  be  later  in  making  itself  evident.  Curvature  is 
noted  but  rarely,  mainly  owing  to  the  fact  that  the  patient  at  once 
assumes  the  supine  position. 

The  special  danger  is  the  spread  of  inflammation  to  the  contents  of 
the  spinal  canal,  meningitis  or  meningomyelitis  occurring  in  about  half 
the  cases,  with  an  almost  invariably  fatal  result.  Death,  which  occurs 
in  about  three-quarters  of  the  cases,  is  either  brought  about  in  this  way 
or  by  general  infection.  Primary  disease  of  the  neural  arch  is  a  more 
favorable  condition  than  that  of  the  body,  owing  to  the  earlier  recogni- 
tion of  the  disease  in  the  former  and  the  greater  ease  with  which 
abscesses  can  be  drained  and  sequestra  removed. 

The  treatment  should  be  conducted  on  the  same  lines  as  for  osteo- 
myelitis elsewhere. 

CARIES  OF  THE  SPINE   (POTT'S  DISEASE). 

Definition. — By  caries  of  the  spine  is  meant  a  destructive 
process  characterized  by  rarefaction  and  absorption  of  the  vertebras, 
leading  in  most  cases  to  angular  curvature.  It  follows  the  same 
course  as  caries  elsewhere,  but  derives  its  special  characteristics  from 
its  situation. 

Etiology. — The  most  common  cause  is  tubercle.  This  is  known 
not  only  by  the  clinical  course  run  by  the  disease,  but  by  the  presence 
in  the  affected  parts  of  the  tubercle  bacillus,  and  the  characteristic 
changes  in  the  tissues  that  it  produces.  Caries,  though  rarely  due  to 
syphilis,  is  met  with  as  the  result  of  both  the  congenital  and  acquired 
forms  of  disease,  but  is  more  commonly  observed  in  the  latter.  The 
cervical  region  is  most  frequently  affected.  Its  diagnosis  will  depend, 
as  a  rule,  upon  the  co-existence  of  other  lesions  pointing  to  syphilis, 
which  are  usually  well  marked.  As  a  factor  in  causation  injury  must 
in  the  main  be  regarded  as  one  of  predisposition.  Its  importance  in 
this  respect  is  shown  not  only  by  the  definite  history  of  injury  so  fre- 
quently obtainable,  but  by  the  partiality  of  caries  for  such  situations  as 
most  readily  lend  themselves  in  childhood  to  damage.  Whether  it 
may  at  times  be  the  sole  agent  in  bringing  about  the  characteristic 
deformity    is    questionable.     The    cases    that    bear   this   interpretation 


CARIES   OF   THE   SPINE.  84 1 

quickly  recover  without  suppuration,  and  the  co-existence  of  tubercle 
cannot  be  determined.  Whatever  share  trauma  may  have  played  in 
originating  the  disease,  there  can  be  no  doubt  of  its  importance  as  a 
factor  in  perpetuating  the  caries,  when  once  established,  in  those  cases 
in  which  the  superincumbent  weight  of  the  body  is  not  relieved  by 
efficient  means. 

Both  sexes  are  said  to  be  equally  affected  by  Pott's  disease,  though 


FIG.  415.— 'Caries  of  lumbar  vertebrae.  The  two  wedge-shaped  portions  correspond  to 
the  bodies  of  the  first  and  second  lumbar  vertebrae.  The  vertebrae  above  and  below  have 
fallen  together,  and  almost  meet  anteriorly  (Guy's  Hospital  Museum). 

our  figures  show  25  per  cent,  more  males  than  females.  Whilst  the 
onset  is  most  common  in  childhood,  the  disease  is  still  frequent  up  to 
sixteen  years  of  age.  It  is  met  with  later  in  life,  though  rarely.  We 
have  known  it  to  commence  and  run  a  typical  course  at  seventy  years 
of  age. 

Pathology. — Site  of  Onset. — Tuberculous  caries  generally  originates  in  the  soft  grow- 
ing bone  between  the  body  of  a  vertebra  and  its  upper  or  lower  epiphyseal  plate,  and 
not  in  the  epiphysis  itself.  It  may  be  compared  in  this  respect  to  the  manner  in  which 
similar  disease  starts  in  the  long  bones  between  the  shaft  and  the  epiphysis.  Occasionally 
the  primary  seat  may  be  on  the  surface  of  a  vertebra,  more  often  on  its  front  and  sides  than 
on  its  posterior  surface  ;  or  at  other  times  in  the  cancellous  tissue  of  the  bodies.  Caries 
commencing  in  the  laminae  and  transverse  processes  is  decidedly  rare.  Some  of  the  cases 
and  specimens  recorded  as  such  are  instances  of  acute  osteomyelitis,  and  not  of  tuberculous 
disease.  If  we  except  the  atlo-occipital,  atlo-axoid,  and  sacrococcygeal  joints,  we  may 
regard  the  synovial  joints  of  the  spine  as  not  liable  to  primary  tuberculous  infection.  In 
these  three  situations  the  starting-point  of  the  disease  is  either  in  the  synovial  membrane  or 
in  those  parts  of  the  bones  that  enter  into  the  articulation.  In  atlo-axoid  disease  the  odon- 
toid process  is  frequently  affected,  and  very  great  danger  of  the  atlas  slipping  forward  on 


842 


INTERNATIONAL    TEXT- BO  OK  OF  SURGERY. 


the  axis  exists.     In  caries  of  the  sacrum  the  process  starts  most  often  in  the  lumbosacral 
region,  though  the  bone  is  occasionally  invaded  from  the  sacro-iliac  joint. 

The  following  is  the  order  in  frequency  with  which  in  our  experience  the  different 
regions  of  the  spine  are  affected  :  Dorsilumbar,  middorsal,  lower  lumbar,  midcervical,  cer- 
vicodorsal,  atlo-  and  occipito-axoid.  Necrosis  is  at  times  present  as  well  as  caries,  and 
fairly  large  sequestra  may  be  thrown  off. 

Course. — From  the  initial  focus  the  disease  spreads  to  the  neigh- 
boring parts,  leading  in  most  cases  to  the  destruction  of  the  bodies  of 
one  or  more  vertebrae  with  their  intervertebral  disks  and  ligaments. 
This   may  be  contrasted  with  the   absorption  brought   about  by  the 


Fig.  416. —  Caries  of  posterior  surface  of  the 
fourth  and  fifth  cervical  vertebrae;  caseous  mass 
in  the  canal,  which  compressed  the  cord  and 
caused  fatal  paraplegia  (Guy's  Hospital  Museum). 


FlG.  417. —  Diffuse  form  of 
caries,  giving  a  honeycombed 
appearance  to  the  vertebrae 
(Guy's  Hospital  Museum). 


presence  of  aneurysm,  in  which  case  the  intervertebral  disks  remain, 
though  the  bodies  above  and  below  are  destroyed.  The  process  is 
more  rapid  in  the  soft,  rapidly  growing  vertebrae  of  young  children 
than  in  adults.  When  caseation  of  the  inflammatory  products  takes 
place  before  the  enclosed  bone  is  absorbed,  sequestra  result.  These 
are  generally  soft  and  friable  in  children,  though  firmer  in  adults. 


CARIES   OF   THE   SPJXE. 


843 


More  rarely  the  disease  is  widely  diffused,  assuming  the  form  of  a  superficial  erosion 
which  affects  the  front  and  sides  of  the  vertebne,  often  over  a  considerable  extent  of  the 
spine  Less  frequently  the  posterior  surface  of  the  bodies  is  affected  in  this  way.  The 
bodies  are  not  completely  destroyed,  as  in  the  preceding  form,  and  so  no  deformity  occurs. 
The  bone  is  irregularly  eroded,  and  is  sometimes  so  riddled  by  the  carious  process  as  to 
assume  a  worm-eaten  or  honeycombed  aspect  (Fig.  417). 


FlG.  418. —  Extreme  angular  curvature  due  to  destruction  of  the  five  upper  dorsal  vertebrae 
(Guy's  Hospital  Museum). 


Angular  Curvature. — When  the  body  of  a  vertebra  disappears, 
its  spine  projects  unduly,  owing  to  the  sharp  angle  produced  by  the 
settling  down  of  the  vertebrae  above  on  those  below  (Fig.  418).  In 
this  way  the  characteristic  boss  is  produced,  its  size  depending  upon 
the  extent  of  bone-destruction.  Deformity  occurs  most  readily  in  the 
dorsal  region,  owing  to  the  normal  convex  curve  backward  of  this 
part.  In  the  midcervical  and  lumbar  regions  a  boss  is  later  in  making 
its  appearance,  as  the  natural  concavities  must  first  be  obliterated.  In 
the  lumbar  region,  moreover,  the  vertebrae  are  larger  and  firmer  and 
less  likelv  to  vield. 


844  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Compression  of  the  Spinal  Cord. — Narrowing  of  the  spinal  canal 
sufficient  to  cause  compression  of  the  cord  but  rarely  occurs  as  the 
direct  result  of  angular  deformity,  even  when  this  is  extensive.  When 
symptoms  of  paralysis  appear,  it  will  be  found  that  these  are  due  in 
the  majority  of  cases  to  the  accumulation  of  inflammatory  products, 
granulation-tissue,  caseous  material,  or  pus  between  the  bone  and  the 
dura  mater.  This  is  accompanied  in  some  cases  by  a  thickening  of  the 
dura  mater. 

Pressure  on  the  cord  may  in  rare  instances  be  due  to  displacement  produced  by  fracture 
through  a  carious  vertebra  (fracture-dislocation),  to  the  sudden  bursting  of  an  abscess,  to 
hemorrhage,  or  to  the  protrusion  of  a  sequestrum  into  the  canal.  As  regards  the  effect  of 
pressure  on  the  cord,  Gowers,  following  Charcot,  states  that  in  all  cases  myelitis  occurs  at 
the  seat  of  compression.  Thorburn  and  others,  however,  maintain  that  pressure  may  lead 
to  paraplegia  by  causing  either  anemia  and  subsequent  degeneration  of  the  cord  or  edema 
from  compression  of  the  extramedullary  veins  and  lymphatics.  These  changes  in  the  cord 
are  followed  by  descending  degeneration  in  the  lateral  columns.  When  compression-para- 
plegia occurs,  the  disease  is  found  to  be  seated  in  the  great  majority  of  cases  above  the  sixth 
dorsal  vertebra. 

In  atlo-axoid  disease  the  canal  may  be  narrowed  by  the  gradual  sliding  forward  of  the 
atlas  upon  the  axis,  the  posterior  arch  of  the  atlas  gradually  approaching  the  odontoid 
process. 

Suppuration. — Abscess  makes  itself  evident  in  about  25  per  cent, 
of  all  cases  affected  with  spinal  caries.  Although  in  the  majority  there 
is  no  obvious  suppuration,  our  failure  clinically  to  detect  pus  does  not 
preclude  the  possibility  of  its  existence.  It  is  probably  much  more 
frequent  than  the  above  figures  indicate.  Collections  of  pus,  as  else- 
where in  connection  with  tuberculous  disease,  may  dry  up  when  deeply 
seated,  especially  in  the  thoracic  region ;  or  the  pus  may  make  its  way 
into  some  hollow  viscus  and  be  discharged  without  detection.  The 
absence  of  evident  suppuration  does  not  argue  in  favor  of  the  carious 
destruction  being  slight :  some  of  the  most  deformed  patients  have 
never  had  an  abscess.  It  occurs  more  commonly  in  connection  with 
superficial  caries,  and  becomes  evident  earlier  in  these  cases.  The  pus 
here  spoken  of  is  the  debris  of  tubercular  disorganization,  and  not 
the  product  of  the  action  of  pyogenic  organisms :  these  are  present  if 
the  abscess  becomes  acute. 

Repair. — When  recovery  takes  place,  repair  is  brought  about  by 
bony  ankylosis  of  the  bodies  above  and  below  the  seat  of  disease.  The 
spine  is  further  strengthened  by  buttresses  of  bone  thrown  out  in  front 
of  the  bodies  of  the  vertebrae,  and  often  by  bony  fusion  of  the  arches 
behind. 

General  pathological  changes,  such  as  cachexia,  lardaceous  disease, 
or  a  sudden  outbreak  of  acute  tuberculosis,  may  be  seen  as  in  other 
chronic  tuberculous  affections. 

Symptoms. — It  is  of  importance  that  spinal  caries  should  be  diag- 
nosed, when  possible,  before  the  development  of  angular  curvature; 
though  when  the  early  symptoms  have  been  slight,  the  patient  may  not 
seek  advice  till  aware  of  a  projection  of  the  spine. 

Pain,  though  variable  in  intensity,  is  present  in  most  cases  either  at 
the  site  of  the  disease  in  the  spine  or  referred  to  a  distance  along  the 
course  of  the  nerves  which  arise  at  the  level  of  the  mischief.  Local 
pain  is,  as  a  rule,  moderate,  the  patient  complaining  commonly  of  gen- 
eral backache  or  weakness,  but  in  acute  cases  it  may  be  very  severe. 


CARIES    OF   THE   SPIXE.  845 

In  these  cases  it  is  often  accompanied  by  a  marked  elevation  of  sur- 
face-temperature and  by  hyperesthesia,  especially  to  heat  and  cold. 
Pain  in  the  back  may  not  be  felt  until  elicited  by  direct  pressure 
upon  the  spinous  processes  or  by  bearing  downward  upon  the  head 
and  shoulders.  It  is  aggravated  by  movement  and  by  the  com- 
munication to  the  spine  of  such  jars  as  are  experienced  by  riding  in 
a  vehicle,  stepping  down  sharply  on  to  the  heels,  or  taking  a  false 
step,  and  even  in  coughing  and  sneezing.  Pain  of  a  neuralgic  char- 
acter is  often  felt  in  the  distribution  of  the  nerves  the  roots  of 
which  are  irritated  or  compressed  at  the  seat  of  inflammation.  Thus, 
in  atlo-axoid  disease  pain  is  referred  to  the  occipital  region ;  in 
cervicodorsal  and  lumbar  caries,  to  the  arms  and  legs  respectively. 
When  the  dorsal  region  is  affected,  intercostal  neuralgia  is  com- 
plained of,  or  pain  referred  to  the  pit  of  the  stomach  and  interpreted 
as  "stomach-ache"  by  children.  The  so-called  "girdle  pain,"  or  sense 
of  constriction,  is  sometimes  met  with  in  adults,  where  there  is  no 
suspicion  of  transverse  myelitis. 

Hyperesthesia  over  the  affected  region  can  sometimes  be  made  out.  In  doubtful  cases 
it  is  not  a  symptom  upon  which  much  reliance  can  be  placed,  as  it  is  often  well  marked  in 
cases  of  neurotic  spine.      Herpes  zoster  is  in  rare  instances  met  with. 

Rigidity  of  the  spine  is  the  most  valuable  of  all  the  signs  of  Pott's 
disease.  The  patient  loses  in  the  affected  region  the  natural  flexibility 
of  the  spine,  moving  the  back  rigidly  as  a  whole  when  asked  to  bend 
over.  If  the  hand  be  placed  on  the  erector  spinae  on  either  side  of  the 
diseased  area,  the  muscle  will  be  found  to  be  firm  and  contracted,  and 
this  may  be  obvious  as  a  distinct  fulness.  Though  exaggerated  when 
stooping,  this  contraction  is  always  present,  and  will  disappear  only 
when  repair  has  taken  place.  The  fixed  and  rigid  position  in  which  the 
back  is  held  leads  to  very  characteristic  movements  on  the  part  of  the 
patient.  When  stooping,  he  will  rest  one  hand  on  his  thigh  or  on  a 
piece  of  furniture,  or  will  cautiously  lower  himself  into  a  squatting 
attitude  by  flexing  his  hips,  knees,  and  ankles,  keeping  the  back  as  stiff 
and  upright  as  possible.  An  adult  with  dorsal  caries  will  cease  to  move 
those  ribs  that  correspond  to  the  seat  of  disease,  and  he  may  eventually 
adopt  an  entirely  diaphragmatic  respiration. 

Deformity. — The  presence  of  a  marked  angular  curvature  (Pott's 
boss)  is  pathognomonic,  but  the  diagnosis  has  frequently  to  be  made 
without  its  aid.  In  cases  unattended  by  pain  it  may  be  the  first  symp- 
tom to  call  attention  to  the  caries.  Although  occurring  at  some  period 
of  the  disease  in  the  majority  of  instances,  those  cases  in  which  the 
disease  assumes  a  diffuse  form  are  unattended  from  first  to  last  by 
deformity.  It  has  already  been  pointed  out  that  an  obvious  projection 
will  result  from  a  slighter  degree  of  mischief  in  the  dorsal  region  than 
elsewhere,  owing  to  the  arrangement  of  the  normal  curves  of  the  spine. 
In  rare  cases  some  lateral  deviation  of  the  spine  may  be  noted  as  an 
early  symptom,  disappearing  as  the  caries  progresses.  It  is  likely  to 
lead  to  an  error  in  diagnosis,  and  careful  attention  should  consequently 
be  paid  to  the  other  signs  of  disease  present. 

Compared  with  other  symptoms,  the  temperature  is  of  little  value, 
for  even  in  acute  uncomplicated  cases  it  may  not  reach  ioo°  F. ;  and  as 


846  INTERNATIONAL    TEXT-BOOK'  OE  SURGERY. 

the  majority  are  of  a  chronic  type,  slight  variations  of  temperature 
within  the  limits  of  i°  F.  will  not  aid  the  diagnosis. 

Atlo=axoid  Disease. — Stiff  neck  with  loss  of  the  power  of  rotation 
of  the  head,  local  tenderness,  and  often  more  or  less  wry-neck  are  early 
symptoms  of  the  disease.  The  aggravation  of  the  pain  caused  by  any 
movement  leads  children  to  support  the  head  by  steadying  it  with  both 
hands  or  by  resting  the  chin  on  some  projecting  ledge  of  furniture, 
though  they  will  also  do  this  in  cervical  disease  lower  down.  Pain  in 
the  course  of  the  great  occipital  nerve  is  sometimes  complained  of.  In 
disease  in  this  part,  or  in  the  upper  cervical  region  generally,  the  posi- 
tion downward  and  forward  in  which  the  chin  is  carried  impedes  the 
entry  of  air  and  gives  rise  to  the  characteristic  grunt.  Examination 
shows  a  variable  amount  of  deep  thickening  with  muscular  rigidity. 
When  displacement  forward  of  the  atlas,  carrying  with  it  the  head,  takes 
place,  a  prominence  is  noticeable  behind,  due  to  the  spine  of  the  axis, 
and  between  this  and  the  occiput  a  sulcus.  In  unilateral  disease  the 
atlas  slides  forward  on  one  side  only,  and  the  chin  consequently  points 
downward  and  to  the  side  opposite  the  lesion.  The  forward  move- 
■  ment  of  the  atlas  on  the  axis  may  lead  to  the  compression  of  the  cord 
between  the  odontoid  process  and  the  arch  of  the  atlas.  If  this  dis- 
placement takes  place  suddenly,  immediate  death  results.  Postpharyn- 
geal abscess,  which  often  forms  in  connection  with  disease  in  this  region, 
is  considered  elsewhere. 

Occipito=atloid  disease  is  less  common  than  the  preceding.  The 
symptoms  are  in  the  main  similar  to  those  just  described,  together  with 
the  loss  of  the  power  to  nod — the  characteristic  action  of  this  joint. 

Sacral  Disease. — Independent  of  sacro-iliac  disease,  the  body  of 
one  of  the  sacral  vertebrae  may  be  affected.  Local  pain,  without  de- 
formity, and  an  abscess  opening  into  the  rectum  have  been  observed. 

Sacrococcygeal  disease  begins  not  uncommonly  in  the  synovial  joint. 
Local  pain,  increased  on  defecation,  with  an  inability  to  sit  down,  will 
draw  attention  to  it.     Its  recognition  requires  no  special  description. 

Abscess. — The  course  of  abscesses  in  connection  with  spinal  caries 
is  determined  by  the  anatomical  arrangement  of  muscles  and  fascise,  and 
they  derive  their  nomenclature  from  the  route  taken  by  them  or  from 
the  situation  in  which  they  become  evident  rather  than  from  the  region 
in  which  they  originate.  They  are  most  often  met  with  in  connection 
with  lumbar  caries,  becoming  relatively  less  common  the  higher  the  site 
of  disease  in  the  spinal  column. 

Cervical  Region. — Postpliaryngcal  abscess  arises  in  connection  with 
the  upper  cervical  region,  and  is  especially  a  sequel  of  atlo-axoid  disease. 
It  may  be  confined  to  the  region  behind  the  pharynx,  and  pushing  the 
posterior  wall  of  this  forward  gives  rise  to  difficulty  in  breathing  and 
swallowing.  It  is  readily  detected  in  this  situation  as  a  fluctuating 
swelling.  In  other  cases  it  may  be  directed  to  the  side  of  the  neck  by 
the  prevertebral  fascia,  and  point  in  front  of  the  sternomastoid  muscle. 
Rarely  it  travels  down  into  the  posterior  mediastinum.  If  it  is  allowed 
to  burst  into  the  pharynx,  death  may  occur  from  suffocation — an  acci- 
dent likely  also  to  attend  the  unskilful  opening  of  the  abscess  in  this 
situation. 

Postesopliageal  abscess  arises  in  connection  with  the  lower  cervical 


CARIES   OF   THE   SPINE.  847 

vertebrae ;  it  may  cause  both  dyspnea  and  dysphagia  from  compression. 
In  a  case  under  the  care  of  one  of  the  writers,  after  producing  pressure- 
symptoms  it  appeared  as  a  deep-seated  swelling  beneath  the  lower 
attachment  of  the  left  sternomastoid. 

Dorsal  Region. — As  the  result  of  dorsal  caries  it  is  uncommon  to 
find  an  abscess  pointing  posteriorly  in  the  thoracic  region  (dorsal 
abscess).  When  suppuration  makes  itself  evident  in  this  situation,  the 
pus  makes  its  way  between  the  vertebral  ends  of  the  ribs,  following  the 
course  of  the  posterior  branches  of  the  intervertebral  arteries  to  the 
back.  It  may  extend  forward  beneath  the  pleura  and  point  at  the  side 
of  the  thorax,  or,  passing  upward  from  the  upper  dorsal  vertebrae,  appear 
at  the  root  of  the  neck.  In  the  lower  dorsal  region  the  abscess  more 
often  tracks  down  beneath  the  ligamentum  arcuatum  internum,  and, 
entering  the  sheath  of  the  psoas  muscle,  gives  rise  to  a  psoas  abscess. 

Lumbal'  Region. — Pus  arising  from  disease  in  this  situation  may 
burrow  through  the  layers  of  the  lumbar  fascia  and  point  in  the  loin 
(lumbar  abseess) ;  it  may  make  its  way  down  in  front  of  the  fascia  cov- 
ering the  psoas  muscle,  to  form  a  swelling  in  the  iliac  fossa  (iliac  abscess) ; 
or,  gravitating  into  the  pelvis,  it  may  escape  through  the  sacrosciatic 
foramen,  giving  rise  to  a  gluteal  abseess.  More  commonly  it  gives  rise 
to  an  iliopsoas  abscess.  The  pus,  entering  the  sheath  of  the  psoas  mus- 
cle, follows  the  course  of  that  muscle  to  the  iliac  fossa,  where  it  may 
give  rise  to  a  large  swelling  which  is  limited  by  the  attachments  of  the 
iliac  fascia.  From  this  situation  it  enters  the  thigh  beneath  Poupart's 
ligament  by  a  narrow  neck  external  to  the  femoral  vessels,  and,  con- 
tinuing its  course,  makes  its  way  beneath  the  femoral  vessels  and  along 
the  profunda  artery  to  the  upper  and  inner  part  of  the  thigh.  Here  it 
will  usually  give  rise  to  a  large  swelling  if  left  to  itself,  and  subsequently 
burst.  At  an  early  stage  careful  palpation  of  the  abdomen  may  reveal 
a  sausage-shaped  swelling  in  the  course  of  the  psoas  muscle,  somewhat 
tender,  and  too  deeply  situated  to  yield  definite  fluctuation.  It  may  be 
detected  in  this  way  when  scarcely  thicker  than  a  finger.  When  the 
abscess  has  reached  the  thigh,  fluctuation  is  readily  detected  between 
the  swelling  below  and  that  above  Poupart's  ligament.  Pus  may  simul- 
taneously make  its  way  into  the  loin  and  point  there  as  a  lumbar 
abscess.  A  psoas  abscess  may  rarely  open  into  the  hip-joint  as  it 
passes  in  front  of  it  in  the  thigh.  It  is  occasionally  bilateral,  especially 
in  connection  with  lumbosacral  caries.  Attention  may  be  drawn  to  the 
presence  of  abscess  by  cruralgia  and  inability  to  straighten  the  thigh. 
It  must  be  remembered  that  psoas  abscess  may  run  its  course  without 
any  interference  with  the  hip-movements  and  without  subjective  symp- 
toms, while  at  other  times  it  may  simulate  hip-joint  disease,  from  which 
it  must  be  distinguished  by  careful  attention  to  the  other  symptoms 
present. 

Pressure  upon  Nerve=roots — The  results  of  the  compression  and 
irritation  of  sensory  nerve-roots  in  the  production  of  peripheral  pain 
have  already  been  referred  to.  This  is  frequently  accompanied  by 
hyperesthesia  of  the  skin,  and  later,  when  the  conducting  power  of 
the  nerves  is  impaired,  by  anesthesia.  Muscular  weakness  due  to 
compression  of  the  motor  nerve-roots  is  not,  as  a  rule,  a  very  obvious 
symptom.     It  will  be   most  marked  when   caries  affects  the  cervico- 


848  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

dorsal  region,  and  the  nerves  to  the  arms  are  implicated.  Paralysis 
due  to  this  cause  will  be  accompanied  by  wasting  of  the  muscles  and 
by  the  reaction  of  degeneration.  Painful  contractions  as  the  result  of 
irritation  of  the  motor  nerve-roots  are  extremely  rare. 

Pressure  upon  the  Spinal  Cord  {Compression-paraplegia). — It  has 
already  been  pointed  out  that  the  most  common  cause  of  paraplegia 
is  pressure  from  the  accumulation  of  inflammatory  products  between 
the  bone  and  the  dura  mater,  generally  in  the  upper  half  of  the 
dorsal  region.  The  result  of  this  pressure  upon  the  cord  is  to 
impair  its  conductivity  and  to  produce  a  paralysis  varying  in  degree 
in  the  parts  below  the  level  of  the  lesion.  The  rapidity  of  onset 
varies  greatly,  the  paralysis  taking  from  a  few  days  to  some  months 
to  reach  a  high  degree  of  severity.  In  rare  cases  it  may  occur 
instantaneously  as  the  result  of  fracture-dislocation  through  a  carious 
vertebra,  or  from  hemorrhage,  or  from  the  sudden  bursting  of  an  abscess 
into  the  spinal  canal. 

Commencing  loss  of  power  in  the  lower  limbs,  together  with  ankle- 
clonus  and  increased  reflexes,  especially  the  deep  ones,  are  early  seen 
as  the  result  of  pressure,  which,  if  unrelieved,  may  involve  the  pyr- 
amidal tracts  or  cause  their  degeneration  and  thus  give  rise  to  spastic 
paraplegia ;  but  absence  of  patellar  reflex,  or  at  least  no  reflex  augmen- 
tation, is  seen  in  disease  below  the  cord-level — that  is,  in  the  area  of 
the  chorda  equina.  Loss  of  sensation  is  subsequent  to  that  of  motion, 
and  as  the  paraplegia  progresses,  loss  of  vesical  and  rectal  control  of 
the  reflex  variety  supervenes. 

It  should  be  noted  that  though  the  cord  is  affected  via  the  meninges, 
yet  focal  symptoms,  as  are  seen  in  meningeal  tumor,  are  practically 
absent  in  caries. 

The  prognosis  of  paraplegia  following  caries  may,  on  the  whole,  be 
considered  as  very  hopeful,  recovery  occurring  in  the  majority  of  cases. 
Nothing,  however,  can  be  positively  predicted  of  any  individual  case, 
however  slight,  nor  does  the  duration  of  symptoms  for  a  year  or  more 
necessarily  preclude  recovery.  When  recovery  fails  to  take  place, 
paralysis  both  of  motion  and  sensation  may  remain,  though  more  com- 
monly sensation  returns  more  or  less  completely,  whilst  palsy  and 
rigidity  of  limbs  remain. 

Diagnosis. — Though,  as  a  rule,  in  late  cases  diagnosis  does  not 
present  any  difficulty,  at  an  early  stage  it  is  only  by  a  very  careful 
attention  to  the  symptoms  of  the  disease  that  an  error  may  in  many 
cases  be  avoided.  We  would  specially  mention  as  significant  the 
marked  local  rigidity  of  the  spinal  muscles  supporting  the  carious 
spine.  This  is  wanting  in  those  somewhat  difficult  cases  of  young  and 
nervous  girls  who  complain  of  pain  and  weakness  in  the  back,  and  who 
have  also  a  fixed  tender  spot  usually  over  one  of  the  dorsal  or  lumbar 
spines,  with  in  some  cases  marked  hyperesthesia  of  the  skin  at  this 
point.  The  absence,  however,  of  any  deformity  and  of  referred  pains, 
and  more  especially  the  perfect  flexibility  of  the  spine,  will  serve  to  dis- 
tinguish these  cases  from  those  of  Pott's  disease.  The  diagnosis  of 
caries  from  new  growths  will  be  referred  to  under  the  latter  heading. 

Prognosis. — Owing  to  the  great  variations  presented  by  spinal 
caries  and  its  complications,  a  mere  statistical  statement  of  recoveries 


CARIES    OF   THE   SPINE.  849 

and  deaths  would  convey  nothing.  It  may  be  safely  stated,  however, 
that,  given  no  evident  complication,  general  or  local,  the  tendency  is 
always  toward  recovery  when  even  moderate  care  is  taken.  Abscess 
adds  to  the  risks,  for  unless  strict  precautions  are  taken,  the  superven- 
tion of  sepsis  aids  the  tuberculous  process.  Angular  curvature  may 
shorten  life  by  the  reaction  on  the  general  health  of  the  displacement 
and  cramping  of  important  organs.  Thus,  in  cervical  disease  the  bend- 
ing forward  of  the  neck,  by  obstructing  the  trachea,  interferes  with  the 
free  entry  of  air ;  in  dorsal  disease  the  approximation  of  the  ribs  and 
limitation  of  costal  movements  seriously  hamper  respiration ;  whilst 
dorsilumbar  disease,  by  cramping  the  abdominal  viscera,  causes  disorders 
of  digestion  and  gives  rise  to  upward  pressure  on  the  diaphragm, 
impeding  deep  inspiration  and  interfering  with  the  heart's  action. 

Death  may  be  brought  about  by  any  of  the  general  complications 
common  to  all  tuberculous  lesions,  such  as  lardaceous  disease,  cachexia, 
or  acute  tuberculosis.  Implication  of  the  spinal  cord  may  bring  about 
a  fatal  termination  from  acute  meningitis  and  myelitis  in  rare  instances, 
but  more  frequently  it  is  the  result  of  compression.  In  atlo-axoid 
disease  fatal  pressure  on  the  medulla  may  follow  dislocation,  or  a  post- 
pharyngeal abscess,  bursting  into  the  pharynx  and  entering  the  larynx, 
may  cause  death  by  suffocation. 

Treatment. — By  Rest. — The  indications  in  the  treatment  of  an 
uncomplicated  case  of  spinal  caries  are  to  relieve  the  focus  of  disease 
in  the  vertebrae  of  the  weight  of  the  superincumbent  parts,  and  to  pro- 
vide against  jars  and  vibrations  of  all  kinds.  The  former  of  these  is 
of  great  importance,  as  the  carious  process,  once  established,  is  largely 
maintained  by  the  pressure  from  above.  They  are  met  most  com- 
pletely by  absolute  rest  in  the  recumbent  position,  and  consequently 
this  mode  of  treatment  should  be  adopted  when  possible  in  all  cases  to 
begin  with.  Mechanical  apparatus  which  allows  the  patient  to  get 
about  does  not,  in  our  opinion,  give  that  rest  to  the  parts  so  necessary 
for  rapid  recovery.  In  acute  cases  rest  is  essential.  The  recumbent 
position  on  a  firm  bed  in  a  cheerful  and  well-ventilated  room  should  be 
adopted.  If  a  child,  the  patient  should  be  carried  out  when  possible 
into  the  open  air  on  his  mattress,  the  same  position  being  rigidly  main- 
tained throughout.  Except  in  caries  of  the  upper  cervical  vertebrae, 
there  is,  as  a  rule,  no  objection  to  the  employment  of  an  additional 
wedge-pillow  for  the  principal  meals.  When  restraint  is  necessary,  a 
strip  of  some  soft  material  should  be  carried  across  the  chest,  with 
apertures  for  the  arms  to  pass  through,  and  fixed  to  the  sides  of  the  bed. 
Limited  movements  of  the  arms,  especially  in  cervical  and  upper  dorsal 
disease,  must  be  insisted  upon.  When  the  disease  is  in  the  cervical 
region,  the  patient  should  be  kept  absolutely  horizontal,  and  the  head 
steadied  by  sand-bags.  A  firm  small  pillow  should  be  slipped  under 
the  neck,  to  provide  support  from  the  occiput  to  the  shoulders.  In 
atlo-axoid  disease  every  care  should  be  exercised  to  provide  against 
fatal  pressure  on  the  medulla  by  the  slipping  forward  of  the  atlas  on 
the  axis.  Even  when  the  onset  and  course  are  distinctly  chronic,  the 
best  results,  as  regards  both  duration  and  deformity,  will  be  obtained 
by  rest  for  a  time. 

By  Supports. — Some  form  of  mechanical  apparatus  for  supporting 
54 


#50  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

the  spine  will  be  indicated  when  all  symptoms  of  acute  diseases  have 
disappeared  during  treatment  by  recumbency,  and  repair  seems  to  have 
made  considerable  headway.  In  some  cases,  especially  in  hospital 
out-patient  practice,  where  the  social  position  of  the  patient  renders  it 
impossible  that  he  should  be  nursed  in  bed,  treatment  by  some  form  of 
support  from  the  commencement  will  have  to  be  adopted.  Though 
invaluable  in  these  cases,  it  cannot  compare  with  rest  in  bed,  as  it  fails 
to  remove  all  downward  pressure  on  the  focus  of  disease  and  to  obviate 
all  jars  communicated  through  the  feet,  and  from  the  point  of  view  of 
deformity,  treatment  by  supports  throughout  is  vastly  inferior.  When 
abscess  is  present  or  paralysis  threatening,  rest  alone  must  be  adopted. 
For  adults,  who  do  not  bear  prolonged  rest  on  the  back  so  well  as 
children,  a  jacket  may  be  employed  throughout.  For  the  purpose  of 
support  the  old  complicated  pieces  of  apparatus  have  been  practically 
superseded  by  the  plaster  jacket  introduced  by  Sayre,  or  the  poro- 
plastic  jacket  designed  to  obviate  certain  disadvantages  attaching  to 
the  latter. 

As  Sayre  showed,  the  acme  of  support  to  a  carious  spine  could  only 
be  obtained  by  the  application  to  the  body,  when  extended,  of  a  closely- 
fitting  rigid  jacket  which  prevents  all  lateral  or  rotary  movement,  and 
which,  by  embracing  the  trunk  equally  at  all  points,  supports  the  body 
above  the  seat  of  disease  while  it  grasps  it  firmly  below.  It  thus 
relieves  the  inflamed  bone  of  much  of  the  superincumbent  weight. 
The  advantages  that  plaster  has  over  felt  are  chiefly  these  :  Its  greater 
rigidity,  its  cheapness,  the  fact  that  the  surgeon  can  himself  readily  fit 
it,  and  that  it  cannot  be  taken  off  by  the  patient.  In  applying  it  the 
following  points  should  receive  attention  :  Care  should  be  taken  in 
making  extension  that  this  should  stop  short  of  producing  pain  or  any 
feeling  of  strain  in  the  back.  All  bony  prominences,  especially  the 
anterior  iliac  spines,  should  be  protected  by  pledgets  of  cotton  wool. 
The  lower  limit  of  the  jacket  should  be  well  down  over  the  iliac  crests  ; 
above,  it  should  be  carried  to  just  below  the  armpits,  and  well  up  over  the 
chest  and  back.  Ashby  and  Wright  recommend  that  it  should  be 
carried  up  crosswise  over  the  shoulders,  the  cervical  part  being  after- 
ward cut  out. 

When  a  strong  prejudice  exists  against  a  jacket  that  cannot  be  taken  off  for  toilet  pur- 
poses, felt  softened  by  heat  may  be  employed.  As  compared  with  plaster,  it  fails  in  efficiency 
from  the  very  fact  that  it  can  be  taken  off,  from  its  liability  to  alter  in  shape,  and  from  the 
circumstance  that  it  fits  less  closely  than  plaster  of  Paris.  Felt  jackets  are  always  weak  over 
the  chest  and  the  crests  of  the  ilia,  two  important  fixation-points.  In  the  later  stages  of 
caries,  however,  it  gives  ample  support,  and  is  then  in  every  way  the  best  material  to  employ. 
When  a  sinus  exists,  the  movable  jacket  is  obviously  better  than  one  of  plaster  of  Paris. 

When  a  patient  is  treated  at  an  early  stage  by  the  recumbent  position,  not  only  may  the 
'boss  not  increase,  but  it  may  lessen  in  size,  as  we  have  seen  happen  on  several  occasions. 
This  is  the  more  likely  to  occur  when  there  is  but  one  prominent  spine.  This  result  might 
he  expected,  since  the  treatment  adopted  removes  the  forces  that  are  displacing  the  neural 
arches  backward,  and  direct  pressure  from  behind  takes  their  place.  When  several  bodies 
are  affected  and  the  angle  is  already  well  formed  and  consolidation  is  assured,  treatment  must 
be  directed  to  supporting  the  back  and  lessening  the  sufferings  of  the  patient  that  result 
from  his  curvature.  Any  good  stays,  with  firm  steels  suitably  shaped,  will  serve  all  purposes, 
-or  the  felt  jacket  may  be  adopted. 

In  cervical  disease  the  felt  jackets  may  be  adapted  to  the  case  by 
being  continued  upward  as  a  collar,  closely  fitting  the  neck  and  moulded 
above  to  the  chin  and   occiput  to  support  the  head.     A  better  con- 


CARIES   OF   THE   SPINE.  85  I 

trivance  is  an  upright  steel  rod  passing  up  from  a  suitable  jacket  to  just 
below  the  occiput,  where,  by  means  of  arms  projecting  from  it  and  con- 
trolled by  screws,  pads  are  made  to  support  the  occiput  and  chin. 
Both  these  methods,  while  taking  off  the  weight  of  the  head  from  the 
spine  below,  limit  lateral  and  rotatory  movements,  and  are  consequently 
adaptable  to  atlo-axoid  disease.  When  the  disease  is  below  the  atlo- 
axoid  joint,  Sayre's  jury-mast  may  be  successfully  employed. 

A  slight  iron  framework,  fixed  below  to  the  body  by  means  of  a  plaster  jacket,  supports 
a  steel  rod,  which  curves  forward  from  behind  over  the  head.  To  the  extremity  of  this, 
which  is  4  inches  above  the  head,  is  attached  a  swivel  cross-bar,  which  carries  a  leathern 
sling  by  means  of  which  the  chin  and  occiput  are  supported.  Sayre  claimed  for  this  jury- 
mast  that  the  head  was  free  to  move  around  while  still  supported,  and  that  thereby  the 
patient's  comfort  was  much  increased.  The  objection  to  this  apparatus  is  that  the  steel  bar 
prevents  the  child  lying  down  properly,  and  in  a  short  time  gets  bent  or  displaced  ;  and, 
moreover,  in  the  recumbent  position  it  ceases  to  exert  any  traction  on  the  head.  While  we 
have  used  it  successfully  in  adults  and  older  children,  we  do  not  recommend  it  for  very  young 
children,  and  it  is  not  suitable  for  atlo-axoid  disease,  on  account  of  the  rotation  allowed. 

Operative  Treatment. — Abscess. — The  treatment  for  abscess  in  con- 
nection with  spinal  disease  should  be  conducted  on  lines  applicable  to 
chronic  abscess  in  connection  with  bone  elsewhere.  As  soon  as  these 
tubercular  collections  become  evident,  they  should  be  opened  and  their 
contents  thoroughly  evacuated,  the  question  of  drainage  being  deter- 
mined by  the  special  exigencies  of  each  case.  In  general,  however,  it 
may  be  said  that  if  the  abscess  can  be  reached  at  all  points,  and  all 
inflammatory  products  removed,  the  case  is  a  suitable  one  for  imme- 
diate closure  as  first  carried  out  by  Barker.  Essential  points  to  be 
attended  to  are  thorough  cleansing  of  the  sac-wall  and  strict  antisepsis 
from  first  to  last. 

An  incision  having  been  made  into  the  abscess  and  the  contents  al- 
lowed to  escape,  the  interior  is  carefully  explored  and  any  septa  present 
are  broken  down.  Water  of  a  temperature  of  I03°-I05°  F.  is  poured, 
or,  better,  conveyed  by  Barker's  flushing  scoop,  into  all  parts  of  the 
cavity.  At  the  same  time  the  walls  are  thoroughly  scraped  to  remove  all 
the  tubercular  lining.  When  scraping  is  likely  to  be  attended  by  such 
risks  as  opening  the  peritoneum,  the  wall  may  be  rubbed  with  sterilized 
sponges.  The  cavity  having  been  well  flushed  and  mopped  dry,  an 
emulsion  of  iodoform  and  glycerin  is  poured  in.  The  greater  part 
should  be  allowed  to  escape  before  the  wound  is  finally  closed,  or, 
better,  the  abscess-cavity  should  be  wiped  out  with  sterilized  sponges, 
leaving  only  such  an  amount  of  iodoform  as  will  adhere  to  the  walls. 

A  postpharyngeal  abscess  should  be  opened  promptly,  to  prevent  the 
possibility  of  a  spontaneous  opening  into  the  pharynx,  with  the  imme- 
diate risk  of  suffocation,  and  later  of  septic  infection.  It  should  be 
reached,  as  was  suggested  by  Hilton,  by  an  incision  carried  along  the 
posterior  border  of  the  sternomastoid,  or  where  most  superficial.  Open- 
ing the  abscess  through  the  mouth  should  be  done  only  in  an  emergency, 
the  patient  lying  on  his  side  with  the  head  inclining  a  little  over  the  side 
of  the  couch,  to  diminish  the  likelihood  of  pus  entering  the  larynx. 

Dorsal  and  lumbar  abscesses  should  be  opened  at  the  most  promi- 
nent point  by  vertical  incisions,  the  further  treatment  being  conducted 
on  the  general  lines  laid  down  above. 

Psoas  abscess  may  be  dealt  with  in  two  ways — either  by  an  opening 


852  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

in  front  in  the  groin,  or  behind  in  the  lumbar  region.  The  former 
alone  is  objectionable,  if  drainage  will  be  required,  since  the  wound  is 
very  likely  to  become  septic,  especially  in  children,  from  the  proximity 
of  the  excreta.  Moreover,  it  does  not  admit  of  the  upper  part  of  the 
cavity  being  reached  for  purposes  of  exploration  and  cleansing.  In 
spite  of  the  difficulties  that  may  attend  the  operation  for  reaching  the 
upper  end  of  a  psoas  abscess  in  many  cases,  the  lumbar  opening  is  the 
one  that  should  be  adopted.  When  the  abscess  has  travelled  as  far  as 
the  groin,  an  opening  should  be  made  in  the  latter  situation  to  facilitate 
the  flushing  and  cleansing  of  the  cavity,  the  anterior  wound  being  sewn 
up  afterward.  The  operation  of  cutting  down  upon  the  psoas  sheath 
from  the  loin  is  not  altogether  free  from  risk  of  wounding  the  perito- 
neum, and  the  difficulties  may  be  increased  by  free  bleeding  from  the 
lumbar  arteries. 

Exploration  of  Bodies  of  the  Vertebra. — In  those  cases  in  which  an 
abscess  is  present  the  bodies  may  be  explored  with  comparative  ease, 
as  was  first  suggested  by  Treves  in  1884,  and  in  some  cases  sequestra 
and  portions  of  diseased  vertebrae  removed.  When,  however,  an 
abscess  does  not  exist,  the  success  of  any  attempt  to  deal  with  carious 
foci  in  the  spine  will  be  in  most  cases  very  problematical.  The  techni- 
cal difficulties  of  exposing  the  anterior  surfaces  of  the  vertebrae  are 
considerable,  and  this  applies  especially  to  the  dorsal  region,  though 
even  here  the  bodies  have  been  successfully  attacked  by  resection  of 
the  posterior  extremities  of  the  ribs.  The  dorsilumbar  and  the  lumbar 
region  is  more  accessible,  but  unless  an  abscess  is  present,  there  is  dif- 
ficulty in  getting  working  room  without  endangering  the  peritoneum. 

In  caries  of  the  sacrococcygeal  joints  and  of  the  coccyx,  removal 
of  this  bone  is  a  sure  and  easy  method  of  cure. 

Treatment  of  Paraplegia. — Since  the  tendency  in  these  cases, 
especially  in  children,  is  toward  recovery,  they  should  be  treated  in  the 
first  instance  by  rest  in  the  recumbent  position.  This  may  be  combined 
with  double  extension  ;  and  Watson  Cheyne,  who  speaks  highly  of  this 
mode  of  treatment,  states  that  recovery  by  this  means  commences 
earlier  and  proceeds  more  rapidly  than  in  recorded  instances  of  lamin- 
ectomy. Improvement  was  noted  by  him  within  three  days.  A  weight 
of  three  pounds  is  applied  to  the  head  and  a  similar  weight  to  the  legs, 
not  for  the  purpose  of  opening  out  the  curved  spine,  but  to  tire  out  the 
muscles  in  the  diseased  area,  which  by  their  contraction  keep  up  the 
inflammation. 

Under  certain  circumstances,  however,  laminectomy  holds  out  the 
only  hope  of  recovery.  Operation  is  indicated  (1)  when,  in  spite  of 
rest  and  appropriate  mechanical  treatment,  symptoms  either  persist 
or  steadily  increase ;  (2)  when  caries  of  the  arches  exists,  and  removal 
of  the  diseased  focus  seems  practicable;  (3)  when  symptoms  directly 
threatening  life  are  present  (Thorburn).  The  question  of  when  to 
operate  is  not  one  that  can  be  definitely  settled.  Each  case  must  be 
decided  on  its  merits,  and  the  time  of  operation  decided  by  the  particu- 
lar symptoms  present  and  the  results  of  treatment.  A  sudden  onset 
of  symptoms,  as  indicating  the  bursting  of  an  abscess  into  the  canal  or 
the  displacement  of  a  sequestrum,  would  suggest  immediate  operation. 
A  fracture-dislocation  occurring  through  a  carious  vertebra  would  not 


SPOND  YLITIS  DEFOKMAXS. 


«53 


be  benefited,  and  should  contraindicate  all  interference,  as  would  also 
the  presence  of  extensive  tuberculous  disease  elsewhere. 

Immediate  Reduction  of  the  Deformity. — This  can  be  at  times 
effected  by  means  of  extension  and  counterextension,  aided  by  direct 
pressure  over  the  projecting  spines,  the  patient  being  under  chloroform. 
The  deformity  is  corrected,  and  the  patient's  trunk  surrounded  by  a 
plaster- of- Paris  jacket.  Since  this  mode  of  treatment  was  first  carried 
out  by  Chipault  in  1893,  a  number  of  cases  have  been  submitted  to 
rapid  reduction  of  the  curvature;  but  the  results  do  not  warrant  our 
recommending  this  mode  of  treatment,  and  on  a  priori  grounds  it 
seems  that  any  benefit  likely  to  accrue  is  more  than  counterbalanced  by 
the  grave  risks  that  such  a  process  involves. 


SPONDYLITIS  DEFORMANS. 

This  is  an  affection  characterized  by  alteration  in  the  normal  curves 
and  restriction  of  the  ordinary  movements  of  the  spinal  column. 

Pathology. — The  changes  in  the  spine  that  give  rise  to  this  disease 
are  identical  with  those  that  affect  joints  generally  in  arthritis  deformans. 

The  articular  cartilages  and  the 
intervertebral  disks  become  ab- 
sorbed, the  bones  become  altered 
in  shape,  and  bony  outgrowths 
take  place  from  the  margins  of  the 


FlG.  419. — Spondylitis  deformans.  Speci- 
men showing  lipping  and  ossification  of  liga- 
ments on  the  right  side  of  the  spine  (Guy's 
Hospital  Museum). 


FlG.  420. —  Erosion  of  vertebrae  by  aneu- 
rysm. The  intervertebral  disks  are  intact 
(Guy's   Hospital    Museum). 


joint-surfaces  and  from  the  contiguous  borders  of  the  vertebral  bodies 
(Fig.  419).     More  or  less   restriction   of   movement  results,  and  this 


854  INTERNATIONAL     TEXT-BOOK  OF  SURGERY. 

may  go  on  to  absolute  fixation  of  a  considerable  portion  of  the  spinal 
column. 

Ankylosis  is  brought  about  in  three  ways  :  By  the  locking  and  occasionally  by  the 
coalescence  of  the  osteophytes  springing  from  adjacent  vertebrae  ;  by  a  direct  bony  union 
of  the  vertebral  bodies  ;  and  by  a  conversion  of  the  ligaments  into  hone.  This  osseous 
change  most  commonly  affects  the  anterior  common  ligament.  Very  rarely  the  spines 
and  laminae  are  found  united  by  bone.  The  costovertebral  articulations  may  be  similarly 
attacked. 

The  lower  dorsal  and  lumbar  vertebrae  are  most  commonly  affected  ;  less  frequently  those 
of  the  upper  cervical  region.  The  atlanto-occipital  and  atlo-axoid  articulations  may  present 
the  characteristic  changes,  and  the  odontoid  process  may  be  considerably  enlarged. 

It  is  a  disease  of  later  middle  or  advanced  life,  but  cases  may  be  met  with  in  young 
adults  and  even  in  children.      It  is  more  common   in  males  than  in  females. 

Symptoms. — The  onset  is  gradual,  commenting  with  pain,  which 
may  be  persistent,  and  stiffness.  The  pain  may  be  felt  in  the  small  of 
the  back,  preventing  stooping,  or  in  the  neck,  interfering  with  move- 
ments of  nodding  and  rotation.  The  patient  sometimes  notices  that 
the  stiffness  affects  his  chest,  restricting  the  ordinary  movements  of 
respiration.  An  alteration  in  the  figure  slowly  takes  place.  There  is 
a  gradual  diminution  in  stature,  and  with  this  an  inability  to  stand 
upright.  In  a  case  that  has  been  progressing  for  some  years  the  back 
presents  one  long  curve  with  the  convexity  directed  backward ;  the 
head  is  craned  forward,  and  the  chest  sunk.  Movements  are  greatly 
restricted,  and  there  may  even  be  complete  fixation  of  a  considerable 
portion  of  the  spinal  column.  When  the  costovertebral  joints  are 
affected,  breathing  is  carried  on  almost  entirely  by  the  diaphragm. 

The  changes  in  the  spine  may  coincide  with  similar  changes  in 
joints  elsewhere,  or  may  be  confined  for  a  long  while  to  the  spinal 
column  and  the  costovertebral  articulations.  The  bony  outgrowths 
from  the  vertebrae  may  compress  the  nerves  in  the  intervertebral 
foramina,  giving  rise  to  neuralgic  pains  in  their  distribution.  Com- 
pression of  the  cord  itself  scarcely  ever  occurs. 

Treatment  will  be  conducted  on  lines  similar  to  that  employed  for 
rheumatoid  arthritis  occurring  elsewhere,  and  can  be  but  palliative. 

EROSION  OF  VERTEBRAE  BY  ANEURYSM. 

The  bodies  of  the  vertebras,  most  frequently  those  of  the  dorsal 
region,  may  be  absorbed  by  the  pressure  of  an  aortic  aneurysm  (Fig. 
416),  and  in  some  cases  an  angular  curvature  is  produced.  Two  or 
three  vertebras  are  usually  affected,  the  bodies  being  destroyed  while 
the  intervening  disks  remain  comparatively  unaffected.  Erosion  is 
usually  attended  by  a  continuous  boring  pain  in  the  spine,  while  the 
pressure  on  the  adjacent  nerves  gives  rise  to  severe  neuralgic  pain  in 
their  distribution.  The  aneurysm  may  reach  the  cord  and  compress 
it,  with  the  production  of  the  usual  symptoms,  and  it  may  even  rupture 
into  the  canal. 

Diagnosis  from  growth  will  be  effected  by  the  presence  of  other 
signs  pointing  to  aneurysm. 


TC'MORS. 


855 


TUMORS. 

Tumors  of  the  Spinal  Column. — The  spine  may  be  the  seat  of 
either  primary  or  secondary  growths,  or  may  be  invaded  by  tumors 
originating  in  neighboring  structures. 

Of  primary  growths,  sarcomata  are  the  most  common,  originating 
either  within  the  bone  or  from  the  periosteum.  Other  forms  of  primary 
growth  are  very  rare.  A  hydatid  cyst  may  develop  in  a  vertebral  body, 
or  a  chondroma  or  exostosis  grow  into  the  spinal  canal,  compressing  the 
cord.      Carcinoma  is  the  most  common  secondary  growth  met  with. 

Symptoms. — The  slow-growing  tumors  will  give  rise  to  symptoms 
of  compression  that  are  marked  by  their  extreme  chronicity.  On  the 
other  hand,  the  malignant  growths 
are  characterized  by  the  acuteness 
of  their  course  and  the  severity  of 
the  pain. 

Pain  is  a  most  prominent  symp- 
tom throughout.  While  seated 
sometimes  in  the  spine  itself,  in 
association  with  local  tenderness 
and  rigidity,  in  its  most  severe  form 
it  is  felt  in  the  distribution  of  the 
nerves  the  roots  of  which  are  in- 
volved in  the  growth.  It  is  intensi- 
fied and  often  rendered  agonizing 
by  the  slightest  movement.  Pain- 
ful muscular  contractions  and  local- 
ized paralysis  may  result  from  com- 
pression of  motor  nerve-roots.  As 
the  result  of  the  infiltration  of  the 
bodies  of  the  vertebrae  with  soft 
growth,  these  may  fall  together, 
with  the  production  of  angular 
curvature  (Fig.  421).  This  may 
take  place  with  such  rapidity  that 
deformity  is  noticed  within  a  few 
weeks  of  the  onset  of  symptoms. 
Curvature  is  not,  however,  invari- 
able. Extension  of  the  growth  to 
the  spinal  canal  will  lead  to  com- 
pression of  the  cord,  with  the  pro- 
duction of  symptoms  similar  to 
those  described  in  caries.  A  rapid 
onset  of  paralysis  is  said  by  Gowers 
to  occur  more  frequently  in  growth  than  in  caries,  all  movement  being 
lost  in  from  twelve  to  twenty-four  hours. 

Diagnosis. — From  caries,  to  which  it  presents  many  points  of 
resemblance,  malignant  growth  may  be  distinguished  by  the  following 
characters  :  Pain  is  much  more  severe  from  the  first,  and  is  intensified 
by  the  slightest  movement ;  the  course  of  the  disease  is  very  rapid, 
and  is  measured  by  months  ;  in  spite  of  rest  and  appropriate  treatment, 


Fig.  421. — Secondary  cancerous  deposits 
in  the  bodies  of  the  dorsal  and  lumbar  verte- 
bra. The  eleventh  dorsal  vertebra  is  re- 
duced almost  to  the  dimensions  of  an  inter- 
vertebral disk,  with  the  production  of  an 
angular  curvature  (Guy's  Hospital  Museum ) . 


856  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

there  is  a  progressive  increase  in  the  symptoms.  Age  is  an  important 
factor.  In  the  first  half  of  life  caries  is  by  far  the  most  common  cause 
of  curvature;  in  the  second  half  caries  and  growth  occur  with  about 
equal  frequency.  The  presence  of  an  abscess  in  connection  with  the 
spine,  or  tuberculous  lesions  elsewhere,  will  point  to  caries.  The 
possible  presence  of  an  aneurysm  or  a  growth  originating  outside  the 
spinal  column  as  the  cause  of  severe  neuralgic  pains  from  pressure  on 
nerves  should  be  borne  in  mind. 

Treatment  is  limited  to  the  relief  of  the  pain. 

Tumors  in  the  Spinal  Canal.— These  may  originate  in  the  cord, 
from  the  membranes,  or  outside  the  dura  mater.  Tumors  outside  the 
membranes  in  most  cases  spring  from  the  vertebral  column,  and  are 
of  a  malignant  type.  Very  rarely  lipoma  and  parasitic  tumors,  chiefly 
echinococci,  develop  in  the  tissue  between  the  bone  and  the  dura 
mater. 

Tumors  of  the  cord  are  far  more  rare  than  those  of  the  membranes. 
They  comprise  most  frequently  gliomata,  sarcomata,  and  gummata ; 
less  often,  tuberculous  masses  are  found.  Growths  arising  in  the  mem- 
branes are  in  a  large  proportion  of  cases  sarcomata  and  myxomata, 
less  frequently  tuberculous  nodules  and  gummata,  and  rarely  benign 
growths  such  as  fibromata,  lipomata,  and  angiomata. 

Tumors  are  found  most  frequently  in  the  dorsal  region.  They  are 
usually  single,  but  sometimes  two  or  three  coexist,  neuromata  of  the 
nerve-roots  being  frequently  multiple. 

Symptoms. — The  earliest  symptom,  and  one  prominent  throughout 
the  course  of  the  disease,  is  pain,  felt  in  the  distribution  of  the  nerves 
whose  roots  are  compressed  by  the  growth.  Unilateral  to  commence 
with,  it  becomes  bilateral  as  the  tumor  increases  in  size.  It  is  generally 
severe  and  neuralgic  in  character.  Pain  is  not,  as  a  rule,  felt  in  the 
spine  until  the  growth  is  large  enough  either  to  press  on  the  dura 
mater  and  bone  or  to  erode  the  vertebrae.  Tenderness  on  pressure 
over  the  spines  may  be  elicited,  but  is  not,  on  the  whole,  very  common. 
Muscular  spasm  due  to  irritation  of  motor  nerve-roots  occurs  not 
infrequently.  All  these  symptoms  are  most  marked  in  meningeal 
tumors. 

As  the  tumor  increases  in  size  it  will  compress  the  spinal  cord,  giv- 
ing rise  to  symptoms  similar  to  those  mentioned  under  the  head  of 
Paraplegia  due  to  Caries.  The  paralysis  is  of  gradual  onset  in  most 
cases.  Occasionally,  crossed  motor  and  sensory  paralysis  results  from 
one-sided  tumors — paralysis  and  hyperesthesia  on  the  side  of  the 
lesion,  anesthesia  on  the  opposite  side.  In  general,  it  may  be  said  that 
rapidity  in  the  progress  of  the  disease,  and  early  paraplegia,  with  a 
history  of  malignancy,  distinguish  the  malignant  form  of  tumor ;  slow- 
ness in  onset  and  the  focal  character  of  the  paralysis  being  rather  seen 
in  innocent  growths. 

Treatment. — If  there  is  reason  to  suppose  that  the  tumor  is' 
syphilitic,  the  usual  remedies  should  be  energetically  employed.  A 
month  will  probably  suffice  to  indicate  the  nature  of  the  disease  and 
the  advisability  or  not  of  further  treatment  on  these  lines.  Tubercu- 
lous tumors  will  be  suspected  from  the  co-existence  of  tuberculous 
lesions  elsewhere.     They  may  yield  to  general  treatment. 


SCOLIOSIS.  857 

Other  tumors  steadily  progress,  and,  apart  from  operation,  treatment 
can  be  directed  only  to  an  amelioration  of  symptoms.  The  prognosis 
being  necessarily  hopeless,  the  question  of  operative  interference 
becomes  an  important  one,  and  will  be  the  more  readily  adopted  now 
that  the  possibility  of  successful  removal  is  established  beyond  doubt. 
The  operation  will  be  conducted  on  similar  lines  to  that  for  the  relief 
of  other  forms  of  compression  (see  Laminectomy).  Tumors  of  the 
spinal  cord  are  not  amenable  to  treatment.  As,  however,  growths  in 
this  situation  cannot  always  be  diagnosed  from  those  originating  in  the 
membranes,  operative  procedures  will  in  the  first  instance  partake  of 
an  exploratory  character.  Tumors  of  the  membranes  are  most  often 
met  with,  being  five  or  six  times  as  common  as  those  in  the  cord  itself. 
As  Allen  Starr  points  out,  an  unfavorable  feature  in  the  prognosis  is 
the  frequency  of  sarcomata,  which  form  over  a  third  of  all  tumors 
found.  In  most  cases  that  have  recovered  the  growth  was  of  a 
benign  character — lipoma,  fibroma,  angioma.  The  results  of  opera- 
tion bring  out  very  clearly  the  importance  of  early  recognition  of  the 
disease  and  removal  of  the  growth  before  irrecoverable  changes  have 
taken  place  in  the  cord. 

SCOLIOSIS  (LATERAL  CURVATURE  OF  THE  SPINE). 

By  scoliosis  is  implied  a  deformity  characterized  by  lateral  deviation 
of  the  spinal  column,  associated  with  rotation  of  the  bodies  round  a 
vertical  axis. 

Pathology. — It  should  be  borne  in  mind  that  the  erect  attitude 
of  the  spinal  column  is  maintained  only  by  muscular  activity.  When 
from  fatigue  the  erect  posture  is  departed  from,  certain  positions  are 
assumed,  both  in  sitting  and  standing,  which  involve  less  expenditure 
of  energy.  In  the  healthy,  vigorous  individual,  owing  to  a  due  balance 
being  preserved  between  rest  and  activity,  there  is  no  tendency  for 
these  "  attitudes  of  rest "  to  pass  beyond  the  limit  of  what  may  be 
considered  a  perfectly  normal  physiological  condition.  But  in  the 
weakly  and  in  those  easily  liable  to  fatigue,  such  positions,  being 
habitually  indulged  in,  will  in  course  of  time  lead  to  the  permanent 
impression  on  the  structures  of  the  spinal  column  of  the  curves  char- 
acterizing these  attitudes,  and  later  to  their  exaggeration.  An  ordi- 
nary example  of  an  attitude  of  rest,  such  as  that  known  as  standing  at 
ease,  will  serve  to  make  the  above  clear.  In  this  position  the  patient 
rests,  say,  on  the  right  leg,  with  the  hip  and  knee  fully  extended,  the 
weight  of  the  body  being  transmitted  through  this  leg.  The  left  leg 
is  flexed  at  the  hip  and  knee,  and  the  pelvis  is  consequently  tilted 
down  to  the  left-hand  side.  The  lumbar  spine  is  thus  thrown  over  to 
the  left.  In  order  to  restore  the  balance  of  the  body,  the  spine  must 
be  curved  over  to  the  right,  and  thus  there  results  a  curve  in  the 
lumbar  region  with  the  convexity  to  the  left.  There  follows,  of 
necessity,  a  compensatory  curve  in  the  dorsal  region,  with  the  con- 
vexity to  the  right,  for  the  purpose  of  balancing  the  upper  part  of  the 
trunk  on  the  lumbar  curve.  In  this  form  of  curvature  the  primary 
curve  is  in  the  lumbar  region,  the  dorsal  one  being  secondary  and 
compensatory.     The  same  results  from  sitting  and  lounging  habitually 


858 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


in  certain  attitudes.  Lateral  curvature  is  brought  about  most  com- 
monly in  this  way.  It  exhibits  itself  mostly  in  children  and  young 
adults,  most  often  in  girls.  They  are  usually  observed  to  have  an 
ill-developed  muscular  system,  and  belong  to  the  class  of  people  who 
are  soon  tired.  There  is  often  an  hereditary  history  of  curvature, 
direct  or  collateral,  on  the  mother's  side ;  and  where  one  girl  in  a  large 
family  suffers  from  scoliosis,  flat-foot  or  knock-knee  is  often  found  in 
another  member  of  it. 

Healthy  adults  may,  as  the  result  of  the  constant  performance  of  certain  forms  of  labor, 
acquire  a  permanent  curvature  of  the  spine,  which,  as  in  the  case  of  the  weakly,  is  to  be 
regarded  as  the  fixation  of  what  is  a  normal  physiological  attitude.  In  this  case,  however, 
it  is  an  attitude  of  activity  that  permanently  impresses  itself  on  the  spinal  column.  This 
form  usually  results  from  carrying  heavy  weights  on  one  shoulder  or  in  one  hand,  and  the 
curve  produced  is  usually  a  long  single  one  involving  the  whole  of  the  dorsal  and  lumbar 
spine,  with  the  convexity  to  the  side  on  which  the  load  is  carried. 


FIG.  422. — Skeleton  from  a  case  of  lateral  curvature,  showing  lateral  deviation  and  rotation 
of  bodies  (Guy's  Hospital  Museum). 


Lateral  curvature  is  seen  occasionally  in  rickety  children,  the 
mechanism  of  production  being  the  same  as  in  adolescents.  A  dis- 
parity in  the  length  of  the  legs,  as  from  old  fracture,  hip-disease,  con- 
genital hip  dislocation,  or  infantile  paralysis,  will  also  be  productive  of 
scoliosis,  and  contraction  of  one  side  of  the  chest  from  empyema  or 
pleurisy  may  lead  to  the  same  result. 

On  account  of  the  unequal  compression  of  the  vertebral  disks 
brought  about  in  any  of  the  preceding  ways,  the  cartilages  become 


SCOLIOSIS.  859 

flattened  on  the  side  of  the  concavity.  If  the  factors  maintaining  the 
curve  persist,  the  bodies  in  time  become  wedge-shaped. 

Rotation  of  the  bodies  of  the  vertebrae  on  a  vertical  axis  always 
accompanies,  and  is  a  necessary  consequence  of,  the  lateral  deviation 
(Fig.  422).  The  bodies  face  round  toward  the  convexity,  while  the 
spines  are  directed  toward  the  concavity,  so  that  the  deviation  of  the 
spinous  processes  does  not  represent  the  full  lateral  curvature.  As 
the  result  of  the  rotary  movement,  the  transverse  processes  on  the  side 
of  the  convexity  are  directed  posteriorly,  carrying  with  them,  in  the 
dorsal  region,  the  ribs,  the  angles  of  which  become  very  prominent. 
In  the  upper  dorsal  region  the  scapula  will  be  pushed  farther  than 
normal  from  the  mid-line.  The  shoulder  on  the  side  of  the  convexity 
will  be  elevated,  and  this  is  frequently  the  first  sign  noticed  by  the 
patient.  The  "  outgrowing  shoulder "  (z.  e.t  the  scapula)  and  "  the 
shoulder  carried  higher  than  the  other  "  are  modes  of  expression  often 
employed  by  parents  in  describing  the  affection.  On  the  side  of  the 
concavity  the  capacity  of  the  chest  is  much  diminished,  the  ribs  being 
crowded  together,  whilst  the  breast  is  sometimes  noted  as  more  promi- 
nent than  on  the  opposite  side. 

Symptoms. — The  patient  should  be  stripped  to  the  hips,  and  the 
clothes  held  by  a  nurse,  to  allow  the  patient's  arms  to  hang  free  and 
also  to  prevent  any  constriction  or  concealment  of  the  loins.  The 
vertebral  spines  are  first  examined  for  any  deviation  from  the  middle 
line.  The  loins  are  then  carefully  compared  as  regards  symmetry,  and 
it  is  here  that  the  earliest  signs  of  curvature  are  noted  in  the  majority 
of  cases.  In  the  slightest  cases  there  will  be  a  want  of  symmetry  in 
the  loins — on  the  side  of  the  curvature,  a  curved  outline  or  at  least  a 
straight  one ;  on  the  concave  side,  a  more  or  less  marked  dipping  in  or 
creasing  of  the  soft  parts.  We  regard  this  as  the  most  important 
objective  sign  of  early  scoliosis. 

In  a  well-developed  case  a  posterior  projection  in  the  loin  of  the 
erector  spine  on  the  side  of  the  convexity,  and  of  the  angles  of  the 
ribs  in  the  dorsal  region  on  the  opposite  side,  will  be  observed.  The 
prominence  of  the  scapula  and  the  heightening  of  the  shoulder  will 
also  be  obvious.  Examined  in  front,  the  breast  on  the  side  of  the 
dorsal  concavity  will  project  more  than  that  on  the  other  side.  In 
advanced  cases  all  the  above  signs  will  be  immensely  exaggerated, 
especially  in  the  dorsal  region,  where  the  rotation  may  be  so  marked 
that  the  angles  of  the  ribs  form  a  ridge  running  more  or  less  parallel 
with  the  spine,  and  easily  mistaken  for  it  by  a  careless  observer. 

The  general  health  of  the  patient  and  the  musculature  should  be 
carefully  noted,  for  no  cure  can  be  effected  so  long  as  they  remain 
defective.  Pain  in  early  cases  is  generally  confined  to  a  general  back- 
ache, muscle-weariness,  and  an  aching  under  the  blade-bones.  In 
advanced  curvature  the  ribs  may  be  so  pressed  together  as  to  cause 
intercostal  neuralgia.  Shortness  of  breath,  palpitation,  and  dyspepsia 
may  be  complained  of  in  severe  cases,  from  limited  movement  of  the 
ribs  and  diminished  capacity  of  the  chest  and  abdomen. 

Treatment. — Formerly,  mechanical  support  was  regarded  as  the 
essential  in  treating  lateral  curvature ;  and  while  there  is  no  denying 
the  comfort  given  by  suitably  chosen  appliances,  they  are  likely,  when 


86o  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

discontinued,  to  leave  the  patient  in  a  more  helpless  state  than  before. 
Having  largely  taken  the  place  of  the  patient's  muscles  and  reduced 
to  a  minimum  the  exertion  necessary  to  maintain  the  erect  position, 
the  patient  becomes  less  and  less  fitted  to  be  again  independent  of 
artificial  support.  However,  in  patients  with  advanced  curvature 
strong  supports  will  be  found  of  very  great  value  to  enable  them  to 
remain  useful  units  of  society ;  though  even  these  cases  may  obtain 
relief  from  some  of  their  complications,  such  as  neuralgia,  oppressed 
breathing,  etc.,  by  using  some  of  the  exercises  indicated  in  less  severe 
forms  of  scoliosis. 

The  treatment  of  lateral  curvature  falls  under  three  heads:  I.  Rest; 
2.  Exercises ;   3.  Supports. 

Rest. — Few  cases  come  before  the  surgeon  in  which  absolute  rest 
is  not  at  first  required.  Most  scoliosis  cases,  when  they  first  present 
themselves,  are  overwrought  and  unable  to  keep  upright,  sinking  every 
moment  into  the  halting  position.  Confinement  to  a  reclining  board 
or  a  flat  couch  is  necessary,  and  no  exercise,  not  even  sitting  up  to 
meals,  should  be  allowed.  The  general  health  and  environment  should 
be  attended  to  and  tonics  administered.  After  the  first  few  days, 
massage  of  the  muscles  of  the  back  should  be  carried  out  daily,  and 
this  on  alternate  days  can  be  extended  to  the  whole  body.  This  regi- 
men should  be  continued  until  the  health  is  obviously  improving,  the 
muscles  developing,  and  all  rachialgia  gone.  Exercises  may  then  be 
substituted  for  the  massage,  and  the  patient  may  sit  up  a  short  time 
for  the  midday  meal.  This  stage  is  usually  reached  in  about  four 
weeks.  When  the  exercises  have  been  learnt,  and  the  patient  is  accus- 
tomed to  them,  and  not  wearied  by  them,  she  may  begin  to  take  short 
walks  of  fifteen  minutes'  duration,  being  previously  fitted  with  suitable 
corsets.  All  rest  must  still  be  taken  lying  down.  In  fact,  sitting  is 
the  last  position  allowed.  The  length  of  time  during  which  the  hori- 
zontal position  should  be  maintained  for  purposes  of  rest  varies  in  every 
case,  but  may  extend  to  twelve  or  even  eighteen  months. 

Exercises. — There  are  numerous  forms  of  exercises  recommended  , 
but,  provided  they  fulfil  certain  conditions,  detail  may  be  disregarded. 
The  conditions  are  active  exercise  of  the  muscles  of  the  back  and 
shoulders,  regularly  carried  out  in  such  a  way  that  there  may  be  at  the 
same  time  an  extending  force  at  work  on  the  spine  itself.  The  follow- 
ing is  an  example  of  an  exercise  without  apparatus.  Extend  the  arms 
fully  over  the  head,  and  let  the  hands  meet  and  clasp ;  now,  straining 
the  arms  and  trunk  upward  as  far  as  possible,  bend  slowly  forward  at 
the  loins,  as  though  in  the  act  of  making  a  plunge ;  then  by  reverse 
action  recover  the  original  position.  In  mild  cases  the  spine  may  be 
seen  to  straighten  at  once.  On  examining  a  case  it  is  well  to  make 
the  patient  go  through  this  exercise,  as  the  surgeon  can  thereby  form 
an  opinion  of  the  extent  to  which  the  curvature  can  be  obliterated. 
Subsidiary  exercises,  which  fail,  however,  in  producing  extension,  are 
the  ordinary  arm-exercises,  with  or  without  light  clubs,  which  are 
mostly  done  at  gymnastic  classes. 

Of  exercises  with  apparatus,  the  cross-bar  hanging  from  two  parallel 
ropes  is  a  favorite.  It  has  two  objections  :  the  hands  are  kept  at  the 
same   level,  and    it    is    too  often   used  merely  to   swing  from,  which 


scoliosis.  86 1 

involves  no  active  muscular  exercise.  We  prefer  to  this  a  simple  rope 
hanging  from  the  ceiling.  Up  this  the  patient  climbs  hand  over  hand 
till  off  the  ground.  At  this  stage  the  hand  on  the  side  of  the  dorsal 
concavity  should  be  the  higher  on  the  rope,  and  thus  a  greater  force 
brought  to  bear  by  means  of  the  trapezius  of  that  side  than  when  the 
hands  are  on  a  level.  After  remaining  in  this  position  a  few  seconds, 
the  patient  climbs  down,  repeating  the  process  again,  until  when  used 
to  it  she  can  carry  it  out  for  ten  minutes  twice  a  day. 

For  the  details  of  other  exercises,  such  as  Sayre's  swing  exercise 
and  Schmid's  exercise,  we  must  refer  to  special  works  on  the  subject. 
In  both  of  these  exercises  direct  force  is  exerted  upon  the  spinal  column 
by  means  of  a  head-piece. 

Supports. — All  rigid  supports,  such  as  Sayre's  and  poroplastic  felt- 
jackets,  as  well  as  the  elaborate  ones  of  leather  and  steel  manufactured 
by  every  instrument-maker,  should  be  reserved  solely  for  incurable 
cases — that  is,  cases  that  are  too  far  advanced  to  admit  of  being  again 
made  "  straight,"  and  in  whom,  even  if  the  tendency  is  not  to  get 
worse,  there  are  the  various  symptoms  dependent  upon  compressed 
viscera.  For  all  cases  under  treatment  with  a  view  to  improvement, 
no  further  support  is  required  than  that  given  by  specially  made  cor- 
sets. There  are,  however,  special  points  in  their  construction  which 
alone  can  make  them  perfect.  They  should  reach  low  down  over  the 
hips,  so  that  a  pelvic  strap  which  forms  part  of  the  corset  may  get  a 
firm  grip  round  the  pelvis,  and  thus  supply  a  point  (Tappui  for  the 
steels  passing  upward ;  and  secondly,  the  steels  should  be  made  of 
thin  metal  and  suitably  sprung,  so  that  without  taking  from  the  patient 
the  necessity  of  using  her  own  muscles,  they  give  just  enough  elastic 
support  to  ease  that  extra  muscle-strain  which  these  patients  are  so 
ill  able  to  bear. 


CHAPTER    XXVI. 
SURGERY  OF  THE  PERIPHERAL  NERVES. 

For  information  upon  the  etiology,  symptoms,  and  treatment  of  those  lesions  of  the 
peripheral  nerves  which  are  not  strictly  surgical,  the  reader  is  referred  to  standard  works 
upon  Neurology.  In  the  present  chapter  only  those  considerations  which  are  of  direct 
surgical  importance  are  discussed. 

WOUNDS    AND    INJURIES    OF    NERVES. 

Contusions. — Traumatic  lesions  of  nerves  range  in  severity  from 
slight  contusions  to  complete  destruction. 

Disturbances  of  function  may  result  from  contusions,  stretchings,  or 
pressures.  They  vary  from  the  numbness,  tingling,  and  motor  paralysis 
of  a  few  moments'  duration  to  entire  loss  of  motor  and  sensory  func- 
tion, which  may  require  months  or  even  years  for  complete  restoration. 
In  some  instances,  indeed,  the  impairment  is  permanent. 

Contusions  usually  affect  those  nerves  which  lie  in  close  contact 
with  bones,  and  which  are  separated  from  the  skin  merely  by  thin 
tissues  or  fibrous  aponeuroses — the  ulnar,  for  example,  at  the  internal 
condyle,  the  anterior  tibial  at  the  head  of  the  fibula,  the  musculospiral 
behind  the  humerus.  Nerves  more  deeply  placed  may  share  in  the 
general  bruising  which  affects  thick  soft  parts,  as  in  crushing  of  the 
thigh  and  of  the  upper  arm,  but  nerves  thus  placed  are  injured  only 
with  difficulty.  At  the  Massachusetts  General  Hospital  one  case  has 
been  observed  in  which  the  nerves  retained  their  function  after  the 
upper  arm  had  been  run  over  by  a  freight  car.  Nothing  was  preserved 
except  the  nerves,  the  blood-vessels,  and  the  skin.  Years  afterward 
the  forearm  was  found  unimpaired  in  nerve-force,  though  the  central 
portion  of  the  upper  arm  was  without  bone  or  muscle. 

The  brachial  plexus  is  not  infrequently  the  seat  of  direct  violence 
from  dislocations  of  the  head  of  the  humerus  and  from  other  injuries 
that  stretch  the  plexus  and  bruise  it  against  the  clavicle  or  against  the 
first  rib. 

Contusions  may  cause  an  irritation  of  the  nerve,  which  at  times 
results  in  a  local  neuritis.     The  nerve  becomes  congested  and  swollen. 

The  symptoms  of  contusion  come  on  immediately,  and  are  the 
effects  of  the  initial  violence.  At  first  there  may  be  only  a  tingling 
sensation  along  the  course  of  the  nerve,  with  more  or  less  pain.  A 
sensation  of  heat  is  often  felt  at  the  peripheral  distribution  of  the  nerve. 
These  symptoms  may  be  followed  by  complete  sensory  and  motor 
paralysis.  When  the  results  of  pressure  upon  the  brachial  plexus 
appear  gradually,  they  are  probably  owing  to  the  secondary  and  pro- 
longed pressure  of  the  dislocated  bone  rather  than  to  the  immediate 
bruising. 

Paralysis  of  the  circumflex  nerve  from  falls  upon  the  shoulder  is 

862 


WOUNDS  AND  INJURIES   OF  NERVES. 


863 


often  observed — frequently  associated  with  impairment  of  the  motions 
of  the  shoulder,  especially  of  raising  the  humerus  upward  and  outward. 
In  these  cases  it  is  hard  to  see  how  a  nerve  can  be  contused  when  so 
deeply  placed  as  the  circumflex,  fully  protected  as  it  is  by  the  deltoid- 
Treatment. — Contusions  usually  result  in  recovery  even  after  com- 
plete paralysis.  Convalescence  is  hastened  by  the  use  of  electrical 
stimulation  and  massage.  Should  the  paral- 
ysis persist  after  reasonable  efforts  at  pallia- 
tive treatment  and  reasonable  time  for  spon- 
taneous recovery,  the  nerve  should  be  ex- 
posed and  its  exact  condition  determined. 
When  the  nerve  is  found  congested  and 
swollen,  as  in  Fig.  423,  relief  of  pressure 
will  be  followed  by  recovery.  Even  if  the 
nerve  has  been  atrophied  and  its  structure 
apparently  destroyed,  relief  of  pressure  may 
be  followed  by  recovery  by  the  renewal  of 
the  nerve  structure  along  the  atrophied 
trunk,  as  in  healing  through  the  cicatrix  of 
a  nerve  suture.  Before  resecting  a  nerve 
that  is  atrophied  and  apparently  destroyed 
by  pressure  some  months  should  be  given 
after  relieving  the  pressure  upon  the  nerve 
for  spontaneous  repair,  especially  if  the  sec- 
tion affected  is  so  extensive  as  to  make 
resection  and  direct  suture  impossible. 

The  patient  from  whom  the  sketch  (Fig. 
423)  was  made  had  complete  musculospiral 
paralysis  caused  by  a  blow  upon  the  back  of  the  upper  arm  by  the  flat 
of  a  wooden  broad-sword.  The  patient  was  a  professional  wrestler, 
and  made,  after  the  relief  of  pressure  by  free  incision  through  the 
triceps,  so  perfect  a  recovery  that  he  was  able  to  renew  his  wrestling 
contests. 

Pressure. — Pressure  long  continued  will  produce  a  paralysis  more 
or  less  complete.  The  pressure  may  be  of  one  or  two  hours'  or  of 
months'  duration.  Examples  of  the  former  are  seen  in  the  effects 
of  the  application  of  tourniquets,  cords,  bandages,  and  of  sleeping  on 
the  arm ;  of  the  latter,  in  the  encroachment  of  neoplasms,  calluses, 
displaced  fragments  of  bone,  and  in  the  use  of  crutches. 

The  musculospiral  is  especially  liable  to  pressure  between  the  lower 
end  of  the  humerus  and  the  flat  tendon  of  the  triceps.  Occasionally 
the  nerve  is  caught  and  compressed  between  the  ends  of  a  broken 
bone.  Paralysis  of  the  musculospiral  nerve,  from  its  position  close  to 
the  humerus,  illustrates  also  the  danger  attending  the  use  of  the  elastic 
tourniquet  in  bloodless  distal  operations.  Such  a  mishap,  though  its 
effects  are  but  temporary,  is  peculiarly  disquieting,  and  makes  inadvis- 
able the  prolonged  use  of  a  tightly  applied  elastic  tourniquet. 

A  rare  form  of  paralysis,  probably  caused  by  pressure,  though 
possibly  by  stretching,  is  that  of  the  brachial  plexus  during  operations 
upon  patients  in  the  Trendelenburg  position.  This  condition  occurs 
occasionally  after  prolonged  elevation,  abduction,  and  outward  rotation 


FIG.  423.  —  Musculospiral 
nerve  as  it  appeared  in  a  case 
of  paralysis  from  contusion  and 
pressure  between  the  humerus 
and  the  tendon  of  the  triceps 
(from  specimen  supplied  by  M. 
H.  Richardson). 


864  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

of  the  arms,  the  plexus  being  pressed  against  the  head  of  the  humerus 
and  under  the  surface  of  the  clavicle,  or  held  up  against  processes  of 
the  deep  cervical  fascia.  The  arms  should  never  be  held  thus  in  the 
Trendelenburg  position,  but  rather  folded  over  the  chest. 

Another  paralysis  is  sometimes  seen  after  the  arm  has  hung  over 
the  edge  of  the  table  during  a  prolonged  operation.  This  is  generally 
a  musculospiral  paralysis,  and  is  caused  by  the  pressure  of  the  arm 
against  the  edge  of  a  table. 

Another  form  of  pressure-paralysis  is  occasionally  caused  by  the 
use  of  crutches.  A  loss  of  power  is  noticed  in  the  muscles  supplied 
by  the  musculospiral,  ulnar,  and  median  nerves  with  more  or  less  ting- 
ling and  anesthesia  in  their  area  of  distribution.  Those  paralyses  caused 
by  a  transitory  pressure  disappear  more  or  less  promptly  upon  the 
removal  of  their  cause. 

Paralyses  occur  also  from  the  pressure  of  inflammatory  exudations, 
from  the  strangling  of  surrounding  neoplasms,  as  well  as  from  direct 
compression  between  neoplasms  and  adjacent  structures  ;  as,  for  exam- 
ple, facial  paralysis  in  the  course  of  inflammations  of  the  mastoid 
and  in  carcinoma  and  other  infiltrating  neoplasms  of  the  parotid ; 
paralysis  of  the  posterior  crico-arytenoids  from  pressure  of  thyroid  or 
mediastinal  tumors  upon  the  recurrent  laryngeal  nerves ;  affections  of 
the  intercostal  nerves  from  the  pressure  of  aneurysms. 

A  marked  surgical  interest  attaches  to  those  symptoms  of  nerve- 
involvement  which  appear  slowly  as  the  result  of  compression  from 
cicatrices,  accidental  or  surgical  (Fig.  424).     Whether  the  manifestation 


Fig.  424. —  Right  external  popliteal  nerve,  showing  involvement  in  a  cicatrix.  Myelin  has 
disappeared,  and  the  normal  nerve-structure  has  been  replaced  by  a  dense  connective  tissue 
(Weigert,  low  power).     (From  specimen  supplied  by  E.  W.  Taylor.) 

be  pain  or  loss  of  power,  the  existence  of  cicatricial  tissue  in  the  course 
of  the  affected  nerve  suggests  a  probable  cause.  Such  affections,  slowly 
appearing  after  injury  or  operation,  unrelieved  by  palliative  treatment, 
require  surgical  exploration  to  determine  the  exact  condition  and  to 
afford  relief. 


WOUNDS  AND   INJURIES   OF  NERVES.  865 

Treatment. — Pressure-analyses  are  usually  self-evident.  Those 
appearing  after  prolonged  application  of  tourniquets  or  after  unusual 
positions  are  so  clearly  the  result  of  a  pressure  already  relieved  that 
proper  measures  of  treatment  do  not  require  a  consideration  of  the 
exact  lesion.  Those  caused  directly  or  indirectly  by  a  violence  suffi- 
cient to  produce  laceration  ;  those  that  may  depend  upon  an  unrelieved 
pressure,  as  upon  bony  growths,  calluses,  dislocations,  entanglements 
in  contracting  scars — all  such  cases  raise  the  question  of  operative 
intervention,  and  therefore  of  a  more  or  less  exact  diagnosis.  For  no 
time  should  be  lost  in  palliative  treatment  if  there  is  a  solution  of  con- 
tinuity, and  none  if  there  is  an  unrelieved  pressure.  It  is  impossible 
in  all  cases  to  say  that  the  causative  lesion  no  longer  exists,  that  the 
pressure  is  relieved,  or  even  that  the  nerve  is  undivided.  To  wait  until 
the  failure  of  palliative  treatment  has  demonstrated  the  need  of  surgery 
requires  from  six  months  to  two  years.  So  long  a  delay  in  cases 
which,  if  the  exact  condition  were  known,  would  require  operations  of 
relief  or  of  repair,  will  in  many  cases  bring  about  hopeless  changes  in 
the  nerve  and  in  the  muscle  supplied.  It  is  necessary,  therefore,  in 
traumatic  cases  to  explore  early,  not  only  for  the  foregoing  reasons,, 
but  for  the  reason  that  the  earlier  the  pressure  is  removed  or  the  sooner 
the  suture  is  applied,  the  better  the  prognosis. 

Paralyses  from  the  pressure  of  dislocated  bones  require  a  reduction 
of  the  dislocation.  If  reduction  is  impossible,  it  may  be  necessary  to 
resect  the  bone,  especially  the  dislocated  head  of  the  humerus.  Paral- 
yses accompanying  fractures  may  require  freeing  of  the  nerve  from  an 
imprisoning  callus  or  from  compressing  fragment-ends.  In  the  great 
majority  of  instances,  however,  the  history  of  the  case,  the  manner  of 
injury,  its  severity  and  its  extent,  the  onset  and  course  of  the  paralysis, 
indicate  with  sufficient  clearness  that  there  is  no  gross  destruction  of 
the  nerve.  Under  such  circumstances  it  is  only  when  palliative  meas- 
ures— electricity,  massage,  showering,  strychnin — fail  after  faithful  use 
for  from  four  to  six  months,  according  to  the  degree  of  paralysis,  that 
the  nerve  should  be  exposed  at  the  seat  of  injury.  In  most  cases 
relief  of  pressure  is  all  that  will  be  required,  though  one  must  not 
be  surprised  to  find,  even  in  apparently  simple  contusions,  serious  im- 
pairment or  even  complete  destruction  of  the  nerve. 

Stretchings. — That  the  stretching  of  a  nerve  is  sufficient  to  inter- 
fere with  its  functions,  particularly  motor,  has  been  demonstrated  by 
the  effects  produced  upon  muscular  spasm  by  the  stretching  of  the 
supplying  nerve.  Stretching  the  facial  nerve  for  spasm  has,  for  example, 
caused  a  transitory  facial  paralysis. 

The  frequency  as  well  as  the  importance  of  accidental  stretching  of 
a  nerve  is  inconsiderable,  unless  the  paralysis  noted  in  a  foregoing 
paragraph  as  occurring  after  prolonged  Trendelenburg  posture  is  owing 
to  a  stretching  of  the  brachial  plexus  rather  than  to  pressure.  Stretch- 
ing, to  be  paralyzing,  must  be  considerable  ;  for  example,  stretching  of 
the  sciatic  for  neuralgia  rarely  causes  functional  disturbances.  More- 
over, stretching  of  the  spinal  accessory  generally  fails  to  relieve,  even 
temporarily,  the  sternomastoid  spasm.  Although  by  stretching  it  seems 
difficult  to  cause  symptoms  of  functional  disturbance,  yet  cases  do 
occur  in  which  functional    impairment  can  be  explained  in  no  other 


866  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

way.  Such,  for  instance,  is  that  following  falls  in  which  the  weight 
of  the  body  is  suddenly  thrown  upon  the  over-extended  palm.  Paral- 
ysis of  the  brachial  plexus  after  prolonged  operations  upon  patients  in 
the  Trendelenburg  position  may  possibly  be  caused  by  stretching  rather 
than  by  pressure  upon  the  clavicle.  In  paralysis  from  stretching,  sur- 
gical intervention  is  rarely  if  ever  required. 

Dislocation  of  Nerves. — Nerves  are  sometimes  thrown  out  of 
their  normal  positions  in  relation  to  bony  prominences.  The  ulnar,  from 
its  groove  behind  the  internal  condyle,  is  most  frequently  dislocated, 
and  the  dislocation  is  sometimes  habitual.  The  peroneal  nerve  is  some- 
times displaced  in  fractures  of  the  tibia  (Deaver).  From  observations 
on  the  cadaver  it  has  been  shown  that  when  the  ulnar  is  freed  from  its 
bed,  flexion  of  the  elbow  dislocates  it.  Sometimes  violent  flexion  will 
tear  the  nerve  from  its  bed.1  According  to  Wharton 2  the  symptoms 
depend  upon  the  method  and  the  severity  of  the  injury — varying  from 
a  tingling  sensation  to  a  complete  paralysis. 

The  causes  of  dislocation  are  muscular  violence  and  direct  violence, 
and,  in  the  case  of  the  ulnar  nerve,  fracture  of  the  internal  condyle. 

Treatment. — Most  cases  require  operative  intervention  to  hold  the 
nerve  in  place ;  though  sometimes  replacement,  rest,  anodynes,  and 
applications  are  sufficient  (Deaver). 

The  ulnar  nerve  is  exposed  and  replaced  in  its  normal  position,  being 
held  there  by  flaps  from  the  triceps  or  by  suturing  the  inner  border  of 
the  tendon  of  the  triceps  to  the  muscular  aponeurosis  of  the  flexor  group. 
Replacement  of  the  nerve  is  followed  by  disappearance  of  symptoms. 
In  no  case  has  neuritis  followed.  In  habitual  dislocations  Kolliker 
advises  deepening  the  groove  and  suturing  the  parts,  the  cicatrix 
tending  to  keep  the  nerve  in  place. 

lacerations,  Sections,  Crushings. — Injuries  to  nerves,  with 
more  or  less  complete  division  of  their  fibers,  direct  crushing  violence 
with  actual  loss  of  substance,  incised  wounds  with  partial  or  complete 
division,  are,  from  every  point  of  view,  of  the  greatest  importance. 

The  commonest  result  of  violence  applied  directly  to  the  nerve  is 
section,  partial  or  complete.  This  is  usually  caused  by  knives,  edged 
tools,  glass,  and  bullets.  The  nerves  at  the  wrist  are  those  most  com- 
monly injured  in  this  manner,  in  which  case  the  tendons  are,  as  a  rule, 
also  divided ;  less  frequently  injured  are  the  nerves  at  the  elbow,  and  in 
the  upper  arm,  the  leg,  and  the  thigh.  Rarely  other  nerves  are  wounded 
— the  facial,  especially  during  operations  upon  or  about  the  parotid, 
the  sciatic  from  falls  upon  glass,  the  pneumogastric  or  phrenic  from 
incised  or  gunshot  wounds.  The  nerve-trunk  may  be  partially  or  com- 
pletely divided.  Lacerated  wounds  of  nerves  result  from  blows  of 
great  violence  by  which  the  soft  parts  are  crushed  and  the  bones  com- 
minuted. In  such  cases  the  destruction  may  involve  a  narrow  section 
or  several  inches  of  the  nerve.  The  whole  trunk  may  be  completely 
destroyed  throughout  the  area  crushed ;  it  may  be  partially  destroyed, 
a  few  fibers  remaining  intact  through  an  irregular  shreddy  mass  of 
variable  extent. 

Diagnosis. — The  condition  of  the  nerve  may  be  determined  by  direct 

1  Dennis's  System  of  Surgery. 

2  Amer.  Jour.  Med.  Set.,  Oct.,  1S95  '■>  report  of  13  cases. 


OPERA  TIONS   ON  NER  FES.  867 

examination  of  the  open  wound.  In  some  instances,  however,  even 
when  the  destruction  is  excessive,  the  skin  is  unbroken.  Whenever  an 
exact  determination  of  the  injury  by  direct  inspection  is  impossible,  the 
nerve  implicated  can  usually  be  demonstrated  by  the  existing  paralysis, 
whether  motor  or  sensory  or  both.  The  muscular  groups  paralyzed 
and  the  skin-areas  affected  will  enable  the  surgeon,  from  anatomical 
knowledge,  to  arrive  at  a  correct  deduction.  The  diagnosis  as  to  the 
seat  of  the  lesion  in  a  given  nerve  will  depend  upon  the  point  to  which 
the  paralysis  of  muscular  groups  rises.  A  paralysis  affecting  the  fore- 
arm, but  not  the  upper  arm — for  example,  the  extensors  of  the  wrist, 
but  not  the  triceps  or  the  supinator  longus — will  indicate  in  a  general 
way  that  the  injury  is  below  the  musculospiral  groove. 

It  may  be  impossible  without  exploration  to  discriminate  between 
contusions  and  lacerations.  Between  a  partial  and  a  complete  division 
of  fibers  the  diagnosis  is  difficult.  The  cause  of  the  injury,  the  manner 
of  its  reception,  the  extent  of  complicating  lesions,  the  completeness 
and  suddenness  of  functional  impairment  must  all  be  taken  into  con- 
sideration.    In  case  of  doubt  operative  exploration  is  indicated. 

Treatment. — In  case  the  nerve  is  found  to  be  bruised,  even  though 
severely,  but  not  divided  or  destroyed,  it  should  not  be  disturbed.  When- 
ever a  nerve  is  found  divided,  it  should  immediately  be  sutured  (see 
Nerve-suture).  Partial  division  requires  suture  of  the  divided  portions, 
the  undivided  fibers  guiding  and  hastening  the  regenerative  process. 
When  there  is  extensive  loss  of  substance,  the  distance-suture  methods 
are  required.  Accidental  sections  of  nerves  during  operations  should 
be  immediately  repaired.  If  the  accident  is  not  discovered  until  after 
recovery  from  the  anesthetic,  a  secondary  suture  is  imperative  as  soon 
as  practicable. 

Motor  fibers  are  sometimes  injured  by  the  avulsion  of  sensory 
nerves.  When  the  infra- orbital  nerve  is  torn  out,  for  example,  the 
motor  filaments  of  the  seventh  to  the  upper  lip  are  often  temporarily 
paralyzed.  Avulsion  of  the  third  division  of  the  fifth  at  the  foramen 
ovale,  or  removal  of  the  Gasserian  ganglion,  usually  involves  the  motor 
filaments  supplying  the  muscles  of  mastication. 


OPERATIONS    ON    NERVES. 

Nerve-SUture. — All  lesions  of  nerves  producing  solution  of  con- 
tinuity require,  sooner  or  later,  suture  of  the  divided  ends.  When 
these  ends  can  be  closely  approximated,  suture  is  easy  and  satisfactory  ; 
when  there  has  been  a  loss  of  an  inch  or  more,  devices  are  necessary 
by  which  the  intervening  space  may  be  bridged  over.  Simple  suture 
demands  that  the  nerve-ends  be  brought  into  accurate  apposition  and 
fastened  there.  In  recent  wounds  the  divided  ends  will  fall  into  easy 
contact ;  in  healed  wounds  it  may  be  necessary  to  stretch  both  distal 
and  proximal  trunks  before  applying  suture. 

The  ends  should  first  be  carefully  trimmed  with  the  knife,  if  neces- 
sary, so  that  they  present  to  each  other  a  clean-cut  surface.  The  ends 
to  be  sutured  may  be  fitted  to  each  other  in  various  ways,  according  to 
the  shape  and  extent  of  the  lesion,  the  ease  of  approximation,  and  other 
considerations  (see  Figs.  425,  426).     Before  suture  is  applied  the  divided 


868 


INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 


nerve-trunks  should  be  allowed  to  fall  into  a  position  as  natural  as  pos- 
sible, anterior  surfaces  being  brought  to  anterior,  posterior  to  posterior. 
If  the  ends  lying  naturally  in  the  wound  do  not  touch  each  other,  they 


Fig.  425. —  Varieties  of  nerve-suture. 


FlG.  426. —  a-e.  Varieties  of  nerve-suture  ;  /, 
nerve-grafting  (after  Willard). 


should  be  stretched  enough  to  permit  approximation  without  undue 
tension. 

The  sutures  may  be  placed  directly  through  the  nerve-trunk,  or 

through  the  sheath  only.  If  through 
the  whole  nerve,  only  three  or  four 
sutures  are  required.  It  has  been  demon- 
strated that  no  injury  is  done  by  trans- 
fixing the  nerve  (see  Figs.  425-427). 
The  preferable  way  is  to  bring  the  sheaths 
together  with  numerous  fine  sutures, 
because  in  this  manner  a  very  perfect  and 
strong  joint  can  be  made.  In  nerves  as 
large  as  the  musculospiral,  ten  or  fifteen 
sutures  may  be  used  ;  in  smaller  branches, 
two  or  three ;  in  the  smaller  nerves — the  facial  or  the  posterior  inter- 
osseous, for  example — a  single  suture  will  suffice. 

Many  surgeons  prefer  fine  catgut  for  suturing,  using  silk  or  chrom- 
icized  gut  only  when  the  tension  is  great.  Fine  silk  is  preferred  by 
the  writer,  because  a  better  approximation  is  possible,  and  the  joint  is 
stronger.  Fine-round  needles  should  be  used  because  they  do  not  cut. 
Larger  and  stronger  suture-material  is  necessary  when  the  nerve  is 
pierced  and  but  two  or  three  sutures  used.  After  completion  of  the 
operation  the  parts  should  be  so  placed  that  the  nerve  is  relaxed  as 
far  as  possible  ;  for  example,  operations   in  front  of  the  wrist   and  in 


FlG.  427. — Nerve-suture. 


OPERATIONS   ON  NERVES.  869 

front  of  the  elbow  require  flexion ;  those  behind  the  wrist  and  behind 
the  elbow,  extension.  Muscular  aponeuroses  and  fasciae  should  not  be 
sutured  over  the  nerve-joint  if  thereby  pressure  is  likely  to  be  caused. 

The  method  of  peripheral  nerve=reproduction  after  suture  has 
been  beautifully  demonstrated  by  Vanlair.1 

Vanlair  cut  the  fibers  of  the  internal  popliteal  nerve  in  the  dog  at  right  angles  with  their 
course  ;  then  sutured,  in  some  cases  bringing  the  surfaces  into  intimate  connection,  in  others 
allowing  them  to  remain  separated  by  several  millimeters,  and  again  in  others  by  a  consid- 
erable distance.  Sublimated  silk  was  used  in  preference  to  catgut,  the  latter  not  offering 
sufficient  resistance  to  assure  a  close  adaptation  of  the  segments.  In  performing  distance 
suture  the  parts  were  connected  by  a  tube  of  Neuber.  The  sutures  were  always  passed 
through  the  epineural  tissue  to  avoid  injuring  the  nerve-fibers.  After  periods  varying  from 
eight  months  to  several  years  the  nerve  was  extirpated,  hardened,  and  stained,  after  which 
sections  were  made  extending  from  several  centimeters  above  the  section  to  the  extremity  of 


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Fig.  428. —  Nerve  (rabbit)  forty-six  days  after  section,  showing  almost  complete  disappear- 
ance of  the  nerve-fibers.  Deeply  staining  portions  are  remains  of  myelin,  not  yet  completely 
disintegrated.  The  nerve  is  cut  in  cross-section  (Weigert,  oc.  4,  im.  fa).  (From  specimen 
supplied  by  E.  W.  Taylor.) 

the  *ierve.  The  external  popliteal  nerve  was  preserved  intact  for  purposes  of  comparison. 
The  result  of  these  experiments  showed  conclusively  that  the  mode  of  reproduction  consists 
in  the  development  of  new  fibers,  commencing  above  the  section,  pushing  through  the  cica- 
tricial tissue  at  the  point  of  apposition,  and  extending  to  the  extremity  of  the  nerve.  The 
course  of  the  new  fibers  is  not  limited  by  the  nerve-sheath,  but  sections  made  above  the 
point  of  division  show  the  new  nerve-fibers  pushing  through  outside  the  sheath.  Sections 
taken  at  this  point  show,  scattered  among  intact  nerve-fibers,  certain  tubes  containing  each 
perhaps  a  half-dozen  very  fine  fibers,  each  manifestly  representing  a  young  axis-cylinder. 
These  tubes  are  known  as  "the  tubes  of  Ranvier  :"  they  seem  to  consist  of  a  membrane 
which  is  apparently  an  old  sheath  of  Schwann,  thinned  and  distended,  containing  slender 
rudimentary  axis-cylinders  embedded  in  homogeneous  protoplasm.  These  rudimentary 
nerve-fibers  spring,  he  considers,  from  old  axis-cylinders  by  fissiparous  proliferation,  being 
put  forth  as  shoots  from  above  the  degenerated  segment.  These  new  fibers  appear  to  be 
capable  themselves  of  further  subdivision  and  proliferation,  producing  thus  new  fibers, 
with  the  same  power  of  multiplication.  A  cut  7  to  8  centimeters  (2.75  to  3.2  inches) 
below  the  section  shows  new  fibers  which  have  acquired  myelin- sheaths  and  appear  as 
healthy  nerves,  though  smaller  and  varying  more  in  size  than  the  corresponding  fibers  in 
the   (healthy)  external  popliteal  nerve. 

1  Atlas  der  pathologischen  Histologic  des  Nervensy stems. 


870  INTERNATIONAL    TEXT- BOOK  OE  SURGERY. 

This  author  shows  an  extremely  instructive  cross  section  of  a  bony  drain  used  to  connect 
two  separate  nerve-segments.  This  preparation  shows  an  Haversian  canal  rilled  with 
nerve-fibers  in  various  degrees  of  development. 

The  prognosis  in  nerve-suture  is  good  if  there  is  a  satisfactory- 
approximation  without  too  great  tension.  Complete  restoration  of 
function  does  not  always  follow,  however,  and  in  some  cases  there  is 
total  failure.  Treatment  should  be  continued  for  many  months,  even 
if  there  is  at  first  little  or  no  improvement.  After  a  few  weeks'  rest 
for  thorough  healing,  the  limb  should  receive  massage,  passive  motion, 
and  electrical  stimulation. 

It  has  been  asserted  that  union  by  first  intention  after  nerve-suture 
occasionally  takes  place.  Indeed,  one  case  is  reported  in  which  com- 
plete restoration  of  function  took  place  within  the  first  twenty-four 
hours.  Rapid  recovery  after  union  of  divided  nerve-ends  suggests  the 
establishment  of  collateral  nerve-supply  rather  than  the  immediate 
transmission  of  nerve-force  through  the  recently  approximated  cut 
surfaces.  The  restoration  of  function  takes  place,  probably  in  all  cases 
(though  with  varying  speed),  through  the  successful  penetration  by 
nerve-cells  and  -bundles  of  the  cementing  tissues  between  the  united 
surfaces  ;  the  more  aseptic,  rapid,  and  complete  the  union,  the  earlier 
and  more  satisfactory  the  restoration.  The  reappearance  of  sensation 
takes  place  sooner  than  that  of  motion — a  fact  that  goes  to  show  that 
the  earlier  symptoms  of  functional  recovery  may  be  owing  to  collateral 
innervation,  which  is  more  easily  established  in  sensory  than  in  motor 
filaments. 

Neuroplasty. — When  the  loss  of  nerve-substance  is  so  great  that 
the  ends  cannot  be  brought  together,  the  intervening  space  may  be 
bridged  either  by  plastic  elongations  of  the  nerve  itself,  or  by  means  of 
catgut,  bone  (decalcified  or  natural),  nerves  taken  from  amputated  limbs, 
or  nerves  from  animals.  The  object  to  be  attained  is  the  supplying 
between  the  separated  ends  of  a  medium  through  which  the  nerve-fibers 
may  be  guided  from  proximal  to  distal  trunks.  It  is  essential  for  the 
successful  bridging  of  the  gap  that  between  the  divided  nerve-ends 
some  medium  be  fastened  through  which  nerve-fibers  may  be  guided 
from  proximal  to  distal  trunk.  The  simplest  and  best  is  illustrated  in 
Fig.  426,  g.  Both  distal  and  proximal  nerve-trunks  are  cut  half  way 
through,  at  a  distance  from  the  divided  end  sufficient,  when  the  nerve  is 
split,  to  close  the  gap.  From  the  bottom  of  the  transverse  cut  the 
nerve-fibers  are  separated  longitudinally  toward  the  gap.  A  sharp 
knife  is  used,  in  order  that  the  nerve-fibers  may  be  cut  apart  rather 
than  crushed  apart,  as  they  are  by  scissors.  The  longitudinal  separa- 
tion should  be  brought  to  within  a  third  or  a  quarter  of  an  inch  of  the 
gap  (Fig.  426,  g).  Small  gaps  may  be  filled  by  thus  splitting  one  end ; 
larger  ones,  by  splitting  both.  The  elongated  nerves  should  be  joined 
end  to  end  as  in  nerve-suture  (Fig.  426,  g).  By  means  of  this  method 
of  distance-suture  long  gaps  may  be  filled.  When  decalcified  bone  is 
used,  a  piece  sufficiently  long  is  placed  between  cut  ends  and  fastened 
there.  Nerves  transplanted  from  the  lower  animals  may  be  accur- 
ately adjusted  between  the  divided  ends  and  sutured.  The  nerve 
may  be  taken  from  a  freshly  amputated  limb,  or  from  a  dog  or  rabbit 
(Fig.  426,/).     The  results  following  these  methods  are,  on  the  whole, 


OPERATIONS   ON  NERVES. 


8/1 


FlG.  429. — Neuroplasty 
(nerve-grafting). 


encouraging,  though  often  unsuccessful.  In  one  case  the  separated 
ends  of  the  musculospiral  nerve  were  successfully  approximated  by- 
resecting  a  portion  of  the  humerus. 

Nerve-grafting. — In  case  it  is  impossible  to  use  any  of  the  fore- 
going devices,  the  cut  nerve  should  be  grafted  upon  the  nearest  large 
nerve  (Fig.  429).  This  method  can  be  applied  only 
in  the  upper  extremity,  or  among  plexuses  where 
large  trunks  are  in  close  proximity  to  the  divided 
one.  The  field  for  the  application  is  therefore 
limited.  Moreover,  it  is  rare  that  a  single  nerve 
like  the  ulnar  is  so  extensively  destroyed  that 
elongation  methods  are  impossible.  Occasionally, 
however,  it  may  be  found  that  grafting  upon  another 
nerve  is  the  only  expedient  practicable.  The  prox- 
imal and  distal  ends  of  the  affected  nerve  are 
trimmed  and  sutured  into  the  adjacent  nerve-trunk, 
the  sheath  of  which  is  first  split  and  dissected 
back  to  receive  them.  The  object  of  this  procedure 
is  to  switch  the  interrupted  nerve-stream  from  the 
proximal  trunk  to  the  selected  nerve,  and  thence 
to  convey  it  through  the  distal  suture  to  its  final 
distribution.  It  has  been  recently  proposed  to  use 
nerve-grafting  to  allay  muscular  spasm  ;  to  graft 
upon  the  facial  nerve,  for  example,  in  facial  spasm, 
fibers  of  the  spinal  accessory. 

The  prognosis  in  nerve-grafting  is  by  no  means  hopeless,  although 
the  results  will  never  equal  those  of  simple  nerve-suture.  Cases  like 
the  following,  communicated  to  me  by  Roswell  Park,  should  encourage 
renewed  attempts  in  suitable  cases : 

"  A  boy  of  fifteen  had  received  a  gunshot  injury  two  years  previously.  A  charge  of  small 
shot  had  blown  away  the  soft  parts  on  the  ulnar  side  of  the  right  forearm  below  the  elbow, 
and  the  ulnar  nerve  was  destroyed.  In  the  course  of  the  next  month  contracture  of  flexors 
occurred,  so  that  the  hand  was  drawn  to  a  right  angle  and  the  fingers  were  clawed.  About 
eighteen  months  after  injury  the  ulnar  was  dissected  out  above  the  inner  condyle  and  grafted 
into  the  median  above  the  elbow.  Its  lower  end  was  dissected  out  near  the  junction  of  the 
upper  and  middle  thirds  of  the  forearm  and  grafted  into  the  median  nerve  at  this  level. 
Rather  than  divide  ail  the  flexor  tendons  to  release  the  hand,  I  made  an  incision  over  each 
bone  a  little  below  the  middle  of  the  forearm  and  resected  an  inch  from  the  shaft  of  each. 

"  Speedy  healing  of  all  the  wounds  and  consolidation  of  the  bones  occurred  ;  the  hand 
was  in  good  position.  In  ten  days  sensation  began  to  return  to  the  parts  supplied  by  the 
ulnar  nerve.  Eighteen  months  later  there  was  almost  perfect  sensation  in  the  same.  The 
boy  writes  well  and  does  everything  with  this  hand  that  he  ever  could  do." 

Nerve -Stretching'  is  an  operation  applicable  to  spasmodic  affec- 
tions of  muscles — to  neuralgias,  tabes,  neuritis,  erythromelalgia,  tet- 
anus, leprosy,  perforating  ulcers,  amputation  neuromata,  bone-callus 
neuromata,  and,  as  an  alternative  procedure,  to  various  other  conditions. 

Theoretically,  nerve-stretching  may  benefit  by  separating  adhesions 
between  the  nerve  and  surrounding  exudates  and  by  relieving  com- 
pressions, bands,  and  entangling  calluses.  It  may  in  some  unknown 
way  favorably  affect  disturbed  functions,  whether  manifested  in  periph- 
eral spasm  or  local  pain.  Stretching  elongates  the  nerve  and,  pre- 
sumably, affects  in  some  way  the  nerve-bundles,  the  nerve-sheaths,  the 
primary  trunk,  and  possibly  the  nerve-roots.     So  far  as  definite  results 


8/2  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

are  obtained  in  the  separation  of  adhesions  and  the  relief  of  surround- 
ing exudates,  the  procedure  is  scientific;  so  far  as  the  results  are 
dependent  upon  elongation  per  sc,  it  is  purely  empirical.  Recourse 
to  nerve-stretching  in  painful  and  incurable  affections  of  obscure  etiol- 
ogy and  pathology  is  justifiable ;  but  its  benefits  are,  to  say  the  least, 
doubtful. 

The  nerve  to  be  stretched  is  isolated  in  accordance  with  anatomical 
principles.  It  is  lifted  from  its  place  with  the  fingers  and  stretched  in 
both  directions,  care  being  taken  not  to  break  it.  The  amount  of 
elongation  is  sometimes  considerable.  In  nerves  like  the  ulnar  or 
musculospiral  an  inch  of  elongation  is  generally  possible,  a  gap  to 
that  extent  being  easily  filled  by  stretching  and  suturing  divided  ends. 

The  strength  of  the  larger  nerves  is  so  great  that  there  is  little  danger  of  breaking  them 
in  stretching.  According  to  Bowlby  (in  Treves)  the  sciatic  nerve  will  stand  a  strain  of  100 
to  160  pounds  ;  the  musculospiral,  median,  and  ulnar,  50  to  80  pounds  ;  other  smaller  nerves 
will  carry  a  weight  of  5  to  10  pounds.  The  larger  nerves  will  therefore  bear  a  strain  fully 
as  great  as  can  be  easily  given  them  with  the  fingers.  The  limb  can  be  lifted  from  the  table, 
for  instance,  by  the  sciatic,  when  the  patient  is  on  his  face.  In  exerting  traction  the  break- 
ing strain  should  be  borne  in  mind,  especially  in  the  case  of  a  nerve  so  important  as  the 
facial.  The  strength  of  cadaveric  nerves  is  doubtless  less  than  during  life.  Moreover, 
•diseased  nerves  are  often  more  friable  than  healthy  ones,  neuralgic  trifacial  trunks  especially. 

Stretching  of  large  nerves  like  the  sciatic  may  cause  serious  lesions  in  the  cord,  though 
in  numerous  experiments  upon  the  cadaver  it  has  been  found  by  the  writer  impossible  to 
exert  any  traction  upon  the  cord  by  a  strain  sufficient  to  break  the  sciatic.  Stretching  of  the 
trifacial  trunks,  even  to  complete  avulsion,  has  never  given  rise  to  any  intracranial  symptoms. 

An  occasional  result  after  nerve-stretching  is  temporary  motor 
paralysis.     This  is  seen  in  stretching  of  the  facial  nerve  for  spasm. 

Neurotomy,  neurectomy,  and  avulsion  are  performed  to  de- 
stroy entirely  the  functions  of  motor  and  sensory  nerves.  Simple 
division  is  sufficient  to  produce  a  muscular  paralysis,  which  will  be  per- 
manent unless  there  is  spontaneous  regeneration  of  the  divided  trunk, 
a  result  never  to  be  expected  in  motor  paralysis,  or,  unless  the  affected 
muscle  has,  like  the  sternocleidomastoid  and  the  trapezius,  a  motor 
nerve-supply  other  than  that  of  the  spinal  accessory.  In  neuralgias 
when,  on  the  other  hand,  there  is  every  reason  to  hope  for  a  perma- 
nent sensory  paralysis  after  neurotomy,  there  will  be  in  practically  all 
•cases  an  early  return  of  pain.  Simple  neurotomy  is,  therefore,  not 
indicated  in  neuralgias,  but  rather  neurectomy,  or,  still  better,  avulsion 
of  the  whole  trunk.  In  some  instances  permanent  relief  will  be  found 
only  after  destruction  of  the  sensory  roots  themselves.  In  neurotomy 
the  nerve  is  exposed  and  divided ;  in  neurectomy  an  inch  or  more  is 
removed ;  in  avulsion  the  nerve  is  grasped  with  hemostatic  forceps 
and  wound  upon  the  forceps  so  as  to  separate  it  from  its  central  and 
from  its  peripheral  attachments.  If  the  nerve  is  grasped  too  strongly 
by  the  forceps  it  is  crushed,  and  only  that  portion  grasped  is  removed. 
In  neuralgia  the  nerve  is  often  so  friable  that  but  a  small  extent  is 
destroyed  by  avulsion  (see  Neuralgia). 

NEURALGIA. 

Neuralgias,  the  most  common  and  the  most  distressing  of  nerve- 
affections,  demand  more  frequently  than  all  others  the  attention  of  the 
surgeon.     The  surgical  measures  at  his  command  are  nerve-stretching, 


NEURALGIA.  873 

nerve-cutting,  nerve-excisions,  nerve-avulsions,  destruction  of  ganglia, 
and  division  of  sensory  roots.  The  efficacy  of  these  measures  is 
usually  in  proportion  to  their  thoroughness  and  to  proximity  to  the 
cerebrospinal  axis. 

Surgical  treatment  is  indicated  when  the  palliative  treatment  of  the 
physician  and  the  neurologist  has  failed,  or  when,  in  cases  of  trifacial 
neuralgia  supposed  to  be  dependent  upon  diseases  of  the  teeth,  dentistry 
offers  no  relief. 

In  trifacial  neuralgias,  which  are  by  far  the  most  common  and  severe, 
destruction  of  the  affected  branches  as  complete  as  possible  is  indicated, 
for  milder  measures  are  of  little  avail.  In  neuralgias  of  the  mixed 
nerves,  to  save  their  motor  functions,  stretching  is  first  advisable.  The 
frequent  and  persistent  neuralgias  of  the  sciatic,  for  example,  justify  a 
procedure  of  even  such  doubtful  efficacy  as  nerve-stretching.  So  severe 
are  some  of  these  neuralgias,  however,  that  the  most  extensive  and 
destructive  operations  are  demanded ;  such,  for  example,  as  amputa- 
tion of  a  whole  extremity,  or  division  of  the  posterior  nerve-roots 
within  the  spinal  canal. 

Neurectomies  in  Trifacial  Neuralgia. — The  efficiency  of  neu- 
rectomies in  trifacial  neuralgias  is  well  established.  Unfortunately  the 
relief  following  this  operation  is  but  temporary.  Avulsion  of  the  main 
divisions  at  their  foramina  of  exit  gives,  as  a  rule,  but  two  years'  im- 
munity from  pain.  Destruction  of  the  offending  filament — the  inferior 
dental  or  the  infra-orbital — gives  about  the  same  period  of  relief.  It 
is  only  when  the  Gasserian  ganglion  is  totally  destroyed  that  relief 
becomes  permanent,  and  the  permanence  of  even  this  relief  is  not  fully 
established. 

In  some  instances,  however,  avulsion  of  the  smaller  nerve,  to  which 
the  pain  is  confined,  effects  a  permanent  cure.  It  seems  the  best  plan, 
therefore,  to  attack  the  external  nerves  first  affected — the  supra-orbital, 
the  infra-orbital,  the  mental,  the  buccal — in  the  hope  of  at  least  two 
years'  relief.  Renewed  pain  may  then  be  relieved  by  deeper  operations 
— upon  the  inferior  dental  by  trephining  the  jaw  or  by  intrabuccal  dis- 
section ;  upon  the  gustatory  within  the  mouth  ;  upon  the  infra-orbital 
by  raising  the  eye  and  breaking  into  the  infra-orbital  canal,  and  by  the 
destruction  of  Meckel's  ganglion  by  Carnochan's  operation.  Recur- 
rence after  these  operations  may  then  be  followed  by  lateral  dissection 
through  the  temporal  and  sphenomaxillary  fossa  after  resection  of  the 
zygoma  and  destruction  of  the  third  division  at  the  foramen  ovale,  and 
the  second  at  the  foramen  rotundum.  Finally,  in  obstinate  and  un- 
controllable pain  the  Gasserian  ganglion  may  be  removed. 

The  gradual  approach  to  this  formidable  operation  thus  outlined 
gives  the  patient  an  almost  certain  immunity  of  four  or  five  years,  and 
this  with  great  safety,  and  with  the  chance  of  much  longer  immunity 
or  even  a  permanent  cure.  The  danger  in  the  peripheral  operation  is 
trivial,  the  disfigurement  slight.  Furthermore,  the  period  of  immunity 
after  so  mild  a  procedure  as  avulsion  of  the  infra-orbital  or  the  inferior 
dental  is  quite  as  long  as  that  after  avulsion  of  the  second  and  third 
divisions.  These  peripheral  operations,  therefore,  are  not  to  be  at  once 
abandoned  in  favor  of  dangerous  and  disfiguring  methods,  but  are 
rather  to  precede  them. 


8/4 


INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 


Neuralgias  limited   to  the  forehead   require  avulsion    of    the  supraorbital   and 

frontal  branches  of  the  ophthalmic  division.  The  supra-orbital  nerve  may  be  isolated  at 
the  supraorbital  notch  or  foramen,  the  frontal  a  little  to  its  inner  side.  The  nerve  should 
be  grasped  firmly  with  ordinary  hemostatic  forceps  and  twisted  out  in  both  directions.  After 
iIk   avulsion  of  this  and  of  other  branches  of  the  trifacial  there  may  be  extensive  ecchymoses. 

The  infraorbital  may  be  isolated  and  avulsed  at  its  emergence  from  the  infra-orbital 
foramen  or  at  any  point  in  its  course  under  the  orbit.  To  expose  the  nerve  as  it  emerges  from 
the  infra-orbital  foramen  an  incision  should  be  made  over  the  foramen  downward  and  out- 
ward, in  the  direction  of  the  very  constant  and  deep  wrinkle,  or  parallel  to  it.  This  cut 
makes  an  almost  invisible  scar.  The  nerve  is  isolated  with  the  blunt  dissector  and  lifted  by 
one  of  the  nerve-hooks  (Figs.  433,435,  436).  To  expose  the  infra-orbital  canal  within  the 
orbit,  an  incision  is  made  along  the  lower  edge  of  the  bony  orbit,  parallel  to  the  fibers  of  the 
orbicularis  palpebrarum  and  through  all  the  tissues  to  the  orbital  fat.  The  eye  is  carefully 
lifted  by  means  of  a  spoon-shaped  spatula  ;  the,  thin-walled  canal  is  broken  open  and  the 
nerve  destroyed.  In  some  instances  it  is  not  impossible  to  isolate  the  nerve  before  it  enters 
the  infra-orbital  canal  in  the  sphenomaxillary  fossa.  Care  must  be  taken  not  to  injure  the 
infra-orbital  artery,  for  in  one  case  at  least  death  has  followed  this  accident.  Avulsion  of 
the  nerve  will  cause  hemorrhage  in  spite  of  every  precaution.  The  bleeding  is,  however, 
only  temporary,  though  it  may  cause  extensive  ecchymoses. 

The  inferior  dental  may  be  found  by  trephining  the  lower  jaw  or  by  careful  dissect- 
ing at  the  foramen  of  exit.      Trephining  over  the  ascending  ramus  or   over  the  angle  is  ac- 


FlG.  430. — Inferior  dental  and  gustatory  nerves  exposed  inside  the  mouth.  The  lower  jaw  has 
been  dissected  at  the  symphysis  to  give  a  better  view  of  the  relation  between  the  gustatory  nerve, 
the  tongue,  and  the  third  molar  tooth  (dissecting-room  preparation,  Harvard  Medical  School). 

complished  after  separating  the  fibers  of  the  masseter,  The  skin-incision  should  be  hori- 
zontal, the  masseter  separation  vertical.  In  one  instance  at  least  a  temporary  salivary  fistula 
followed  the  vertical  skin-cut. 

Avulsion  of  the  inferior  dental,  as  well  as  of  the  gustatory,  may  be  performed  within  the 
mouth.  This  route  of  isolating  the  gustatory  is  extremely  satisfactory,  as  it  is  easy  and 
efficacious.  The  operation  may  be  performed  under  cocain.  Operation  upon  the  inferior 
dental  through  the  mouth  is  much  more  difficult.  In  the  latter  operation  the  dental  foramen 
may  be  exposed  by  an  incision  along  the  anterior  and  internal  border  of  the  ascending  ramus 
(Fig.  430).      Through  this  incision  careful  dissection  backward  will  bring  into  easy  percep- 


NEURALGIA.  875 

tion  the  sharp  spur  of  the  dental  foramen  into  which  the  nerve  and  artery  will  be  found 
entering.  The  gustatory  nerve  (Fig.  430)  is  exposed  by  an  incision  just  behind  the  last 
molar  tooth.  The  nerve  emerging  from  the  pterygoids  passes  downward,  forward,  and 
inward  to  the  tongue,  lying  close  to  the  last  molar  as  it  bends  toward  the  tongue.  It  may 
be  exposed  also  in  the  floor  of  the  mouth  by  the  side  of  the  tongue.  As  it  may  be  involved 
in  cancer  of  the  tongue,  the  gustatory  frequently  requires  division. 

The  buccal  nerve  (sensory)  may  be  exposed  by  an  incision  through  the  cheek  in  front 
of  the  coronoid  process.  The  nerve  emerges  just  between  this  process  and  the  insertion 
of  the  temporal  muscle.  The  auriculotemporal  branch  of  the  third  division  is  frequently 
affected  alone.  This  nerve  accompanies  the  temporal  artery,  and  may  be  found  by  careful 
dissection  at  the  point  where  the  artery-  crosses  the  zygoma. 

In  many  cases  of  trifacial  neuralgia  a  small  branch  of  one  division 
and  a  small  branch  of  another  will  be  affected.  Under  these  circum- 
stances each  small  branch  should  be  avulsed  if  the  pain  is  always 
limited  to  these  branches.  Neuralgias  that  shift  from  one  branch  to 
another,  probably  indicating  an  extensive  central  involvement  with 
widely  separated  and  transitory  manifestations,  demand  at  once  the 
destruction  of  the  main  trunks,  or  even  of  the  Gasserian  ganglion  itself. 

These  more  extensive  operations  are  indicated  also  by  the  recur- 
rence of  pain  after  the  peripheral  neurectomies.  In  many  cases,  too, 
the  extent  and  the  persistence  of  the  pain  require  the  major  operation 
as  the  initial  procedure. 

Destruction  of  the  main  trunks  is  now  accomplished  by  dissection 
of  the  sphenomaxillary  fossa  through  the  temporal  region. 

Destruction  of  the  second  division  with  removal  of  Meckel's  ganglion  maybe  accom- 
plished by  Camochan's  operation,  first  undertaken  in  1856.  The  infra-orbital  nerve  was  fol- 
lowed back  to  the  ganglion  by  trephining  the  antrum,  and  the  posterior  walls  of  the  antrum, 
through  a  V-shaped  incision  under  the  orbit.  Various  modifications  of  the  operation  have 
been  practised,  the  object  of  all  being  to  reach,  with  as  little  disfigurement  as  possible,  the 
sphenomaxillary  fossa.  Liicke  made  an  incision  starting  from  a  point  just  above  the  exter- 
nal canthus  of  the  eye,  passing  backward,  then  downward  and  forward.  The  masseter  was 
divided  below  the  zygoma,  and  the  zygoma  turned  back.  In  this  way  the  sphenomaxillary 
fossa  was  exposed  and  the  nerve  resected  at  the  foramen  of  exit.  Lossen  cut  the  temporal 
fascia  and  turned  the  masseter  back  with  the  zygoma.  Nussbaum  in  1863  and  Billroth  in 
1864  reached  the  nerve  by  performing  Langenbeck's  osteoplastic  resection  of  the  superior 
maxilla.  Reyher  first  tied  the  carotid  and  then  performed  Lossen's  operation.  Wagner 
made  an  incision  below  the  eye,  and  with  the  eye  raised  out  of  its  bed  followed  the  infra- 
orbital nerve  back  to  the  foramen  rotundum.  Gerster  turned  back  a  section  of  the  malar 
bone,  and  in  that  way  reached  the  sphenomaxillary  fossa. 

Excision  of  the  third  division  of  the  fifth  nerve  was  first  performed  about  twenty-five  years 
ago  by  Pancoast  of  Philadelphia,  who  raised  a  cheek-flap  with  its  base  at  the  zygoma,  sawed 
through  the  zygoma,  and  turned  it  down  with  the  masseter  muscle.  The  coronoid  process 
was  excised  and  the  temporal  muscle  turned  up.  KronleM  s  operation  was  similar,  but  his 
flap  was  turned  downward  from  the  top  of  the  zygoma,  and  the  coronoid  process  upward 
with  the  temporal  muscle.  In  1887  or  1888  Salzer  made  a  larger  flap,  with  its  base  at  the 
zygoma.  The  temporal  fascia  and  muscle  were  separated  from  their  attachments  and  turned 
down  with  the  zygoma.  In  1891  Mixter  combined  the  two  operations  of  neurectomy  of  the 
second  and  third  divisions  by  exposing  first  one  and  then  the  other  foramen,  after  dividing 
the  temporal  muscle. 

Carnochan's  Operation  may  be  employed  in  suitable  cases — cases  in  which  the  pain 
is  confined  exclusively  to  the  second  division  and  its  branches.  A  V-shaped  incision,  with 
its  apex  downward,  is  made  about  Yz  inch  below  the  infra-orbital  foramen.  A  sharp-pointed 
bistoury  is  thrust  through  the  cheek  into  the  mouth  from  the  apex  of  the  incision,  and 
carried  downward  through  the  cheek  to  a  point  midway  between  the  angle  of  the  mouth 
and  the  center  of  the  lip.  The  flaps  thus  formed  are  turned,  one  upward,  another  back- 
ward, and  a  third  forward,  exposing  the  bony  anterior  surface  of  the  superior  maxilla.  An 
opening,  with  its  center  a  little  below  the  infra-orbital  foramen,  and  from  y2  to  %"  of  an  inch 
in  diameter,  is  then  made  in  the  anterior  wall  with  a  trephine  or  chisel.  Next,  an  opening 
of  34^  to  ^  of  an  inch  is  made  in  the  posterior  wall.  The  groove  of  the  infra-orbital  nerve 
is  opened  from  the  antrum  and  the  nerve  followed  back  to  the  foramen  rotundum,  where  the 
second  division  is  divided  with  a  blunt-pointed  pair  of  scissors.  The  operation  is  unneces- 
sarily disfiguring,  yet  in  its  main  points  it  is  still  used. 


876 


/.\  TERNATIONAL    TEXT-BOOK  OF  SURGERY. 


In  view  of  the  generally  admitted  necessity  of  thoroughness  in 
operations  upon  trifacial  neuralgias,  and  especially  upon  neuralgias 
intermittently  affecting  widely  separated  filaments,  now  of  the  second 
and  now  of  the  third  divisions,  the  more  extensively  destructive  opera- 
tions seem  to  grow  in  favor.  Exposure  of  the  sphenomaxillary  fossa 
in  avulsion  of  the  third  division  by  Lossen's  operation  was  followed  by 
Mixter's  operation  of  avulsing  both  second  and  third  divisions  through 
the  same  incision.  This  operation,  as  understood  and  performed  by  the 
author,  is  as  follows  : 

The  principal  anatomical  feature"  in  this  operation  consists  in  the  exposure  of  the  fora- 
men rotundum  and  the  foramen  ovale  by  section  or  displacement  of  the  temporal  muscle. 
The  first  step  consists  in  the  depression  of  the  zygoma.  A  curved  incision  with  its  base  at 
the  zygoma  and  its  convexity  upward  is  made  from  the  external  margin  of  the  orbit  to  the 
lobe  of  the  ear.  The  ends  of  the  cut  must  go  ]/z  inch  below  the  zygoma.  The  zygoma 
itself  is  then  sawed  in  front  and  behind,  the  cuts  being  slightly  beveled  from  without  in- 
ward, and  care  being  taken  to  avoid  opening  the  articulation  of  the  lower  jaw.  To  permit 
satisfactory  replacement,  the  fat  and  fascia  attached  to  the  zygoma  are  depressed  with  it. 
The  zygoma,  with  the  masseter  and  other  attachments,  is  now  pulled  downward,  the  tem- 
poral muscle  being  thus  exposed.  If  the  operator  is  skilled  enough  in  the  subsequent 
manipulations,  he  may  omit  the  cutting  of  the  temporal  muscle.  Should  he  require  a  good 
deal  of  room,  he  may  divide  the  muscle  transversely  and  follow  the  bone  directly  to  the  fora- 
mina, being  guided  entirely  by  the  sense  of  touch.  The  most  desirable  method,  because  the 
least  destructive  and  the  least  disfiguring,  is  that  of  leaving  everything  intact  after  cutting  the 
zygoma,  and  proceeding  to  the  second  division  in  front  of  the  temporal  muscle,  and  then  to  the 
third  behind  that  muscle.  The  guide  to  the  foramen  rotundum  and  the  second  division  is  a 
spur  of  the  great  wing  of  the  sphenoid ;  to  the  foramen  ovale,  the  base  of  the  pterygoid 


FIG.  431. — Retractor  for  deep  operations  on  the  second  and  third  divisions,  fifth  nerve. 

process  of  the  sphenoid.  To  approach  the  foramen  rotundum,  the  zygoma  is  pulled  down- 
ward, the  temporal  muscle  backward.  Retractors  of  special  construction  aid  in  exposing 
the  deep  parts  (Fig.  431).  The  most  desirable  attributes  of  the  retractors  are  sufficient 
depth,  breadth,  and  smoothness,  to  give  a  clear  view  without  lacerating  veins.  The  spur 
on  the  great  wing  of  the  sphenoid  is  quickly  exposed.  If  prominent  and  in  the  way,  it  may 
be  chiselled  off,  care  being  taken  not  to  open  the  middle  fossa.  By  this  time  the  anterior 
field  will  be  so  bloody  that  it  must  be  packed  with  gauze.  The  retractors  are  therefore 
shifted  to  the  field  behind  the  temporal  muscle.  The  chief  points  about  the  foramen  oval*1 
are  (1)  that  it  is  situated  at  the  base  of  the  pterygoid  process  and  (2)  that  it  is  about 
1%  inches  internal  and  a  little  posterior  to  the  anterior  margin  of  the  posterior  attachment 
of  the  zygoma.  The  index  finger  is  worked  inward  and  slightly  backward,  starting  from 
the  base  of  the  zygoma,  until  the  base  of  the  pterygoid  processes  is  reached,  where  the 
foramen  can  be  usually  recognized  by  the  sense  of  touch   (Fig.  432). 

In  penetrating  to  the  foramen  ovale  the  pterygoid  muscles  may  be  disregarded.  They 
yield  readily  to  the  fingers  or  to  the  retractors ;  they  are  but  slightly  injured,  and  their 
functions  are  subsequently  unimpaired.  If  the  temporal  muscle  is  cut,  and  the  pterygoids  with 
their  attachments  to  the  skull  are  extensively  lacerated,  their  impairment,  as  well  as  that  of 
the  temporal  muscle  itself,  is  considerable,  and  movements  of  the  jaw  are  often  limited. 
As  soon  as  the  depths  of  the  wound  are  visible,  after  the  retractors  have  been  carefully  and 
deeply  placed  with  reference  to  the  situation  of  the  foramen,  the  zygoma,  and  the  pterygoid 
base,  the  nerve  will  often  be  visible.  Should  it  be  still  obscured,  its  position  may  be  sought 
by  repeated  thrusts  of  the  right-angled  hook  (Fig.  433),  by  careful  searching  with  the 
blunt  dissector,  or  by  following  down   a   motor  filament  from   the  coronoid  notch.      Some- 


NEURALGIA. 


877 


times  the  nerve  will  be  found  separated  into   two  parts  by  a    spur  of  bone  close   to  the 
foramen. 

In  many  cases  the  application  of  the   retractors  will   cause  rupture  of  veins  and  even  of 


FlG.  432. — Third  division  at  foramen  ovale  :  temporal  muscle  drawn  forward. 

arteries,  with  free  hemorrhage.      The  field  must  then  be  packed  with  gauze.      In  the  mean- 
time the  retractors  may  be  shifted  to  the  anterior  field,  which  will  be  found  perfectly  dry. 


Fig.  433. — Nerve-hook. 

The  second  division  will  be  found  just  in  front,  and  to  the  inner  aspect,  of  the  base  of  the 
spur  previously  removed.      It  may  be  easily  grasped  by  means  of  a  suitable  hook  (Figs.  430, 


Fig.  434. 


Fig.  435- 
Figs.  434,  435. — Instruments  for  hooking  up  nerves. 

435),  and  drawn  out  enough  for  the  application  of  strong  hemostatic  forceps,  by  means  of 
which  it  is  forcibly  avulsed  ( Fig.  436).  The  anterior  wound  is  again  packed  with  gauze,  and, 
if  necessary,  renewed  search  is  made  lor  the  posterior  division.    The  nerve,  if  not  seen,  maybe 


878 


INTERNATIONAL    TEXT  BOOK  OF  SURGERY. 


caught  up  by  means  of  the  nerve-hooks  passed  about  the  foramen  ovale,  as  demonstrated 
by  the  finger  or  the  right-angled  hook.  When  recognized  it  should  be  grasped  by  hemo- 
static or  other  suitable  forceps  and  slowly  avulsed  in  both  directions.  The  motor  branches 
of  the  third  division  should,  if  possible,  be  avoided.  As  a  matter  of  fact,  they  are  usually 
destroyed.      The  posterior  wound  is  then  packed  with  gauze  for  hemostasis  while  the  anterior 


Fig.  436. — Operation  on  second  division,  fifth  nerve,  in  sphenomaxillary  fossa:    temporal 
muscle  drawn  backward. 


gauze  is  being  removed.  As  soon  as  the  oozing  has  ceased  the  remaining  gauze  is  removed, 
the  zygoma  is  stitched  into  place,  and  the  wound  closed.  If  oozing  is  considerable,  a 
gauze  wick  may  be  left  from  twenty-four  to  forty-eight  hours. 

If  the  temporal  muscle  is  divided,  there  will  be  more  room,  and  the  nerve  will  be  more 
easily  found.  It  will  be  necessary,  however,  to  suture  the  muscle,  and  the  deformity  and 
muscular  impairment  will  be  greater. 

The  operation  as  described  above  is  at  times  very  difficult,  chiefly 
on  account  of  venous  hemorrhage.  In  this  operation,  as  in  operations 
upon  the  Gasserian  ganglion  when  performed  upon  elderly  patients, 
hemorrhage  from  veins  is  almost  always  unavoidable,  the  veins  being 
everywhere  abundant  and  thin-walled.  Arterial  hemorrhage  never 
occurs  in  this  operation.  However  familiar  the  surgeon  may  be  with 
the  anatomy  of  the  parts,  he  will  find  it  extremely  useful  to  have  a 
skull  at  hand  for  reference. 

After  even  so  extensive  a  destruction  of  nerve-trunks  there  will  often 
be  for  a  day  or  two  complaint  of  pain  in  the  course  of  the  avulsed 
nerve.     This  will  soon  subside,  however,  and  relief  will  be  complete. 

Removal  of  the  Qasserian  Ganglion. — Removal  of  the  Gasserian 
ganglion  should  not  be  performed  in  feeble  patients  or  in  those  suffer- 
ing from  serious  diseases,  for  the  danger  of  the  procedure  is  great. 


NEURALGIA. 


879 


Two  methods  are  used — that  of  Rose  and  that  of  Krause-Hartley.  Rose's  method  con- 
sists in  exposing  the  skull  deep  in  the  temporal  fossa  by  displacing  the  zygoma  downward 
at  and  external  to  the  foramen  ovale.  A  trephine  opening  is  made,  through  which  the  third 
division  is  followed  to  the  ganglion.  Removal  of  the  ganglion  is  accomplished  piecemeal 
by  means  of  suitable  instruments.  The  chief  objections  to  this  method  are  that  it  is  very 
difficult  to  see  what  is  being  done,  that  hemorrhage  is  hard  to  control,  and  that  serious  injury 
may  be  caused  to  important  structures. 

The  Krause-Hartley  method  (Fig.  437)  consists  in  removal  of  a  portion  of  the  skull  at 
the  temporal  fossa  sufficiently  large  to  permit  the  full  recognition  and  intelligent  isolation  of 


Fig.  437. — Dissection  showing  Krause-Hartley  operation  on  Gasserian  ganglion.  The 
brain  and  dura  mater  are  shown  lifted  by  means  of  a  spatula,  exposing  the  ganglion  and  its 
three  divisions  passing  to  their  respective  foramina. 

the  ganglion  and  its  technically  perfect  removal  without  injury  either  to  the  cranial  sinuses 
or  *he  motor  nerves.  The  application  of  this  method,  as  practised  by  the  author,  is 
as  follows :  A  curved  incision,  with  its  convexity  upward,  is  made  above  the  zygoma 
of  the  affected  side.  A  section  of  bone  similar  in  shape  to  the  skin-flap,  though  some- 
what smaller,  is  next  cut  from  the  squamous  portion  of  the  temporal  and  the  greater 
wing  of  the  sphenoid.  The  upper  convex  portion  of  the  bone-cut  must  first  be  made  with  a 
saw,  as  in  bone-flap  exposures  of  the  motor  areas.  The  base  of  the  flap  must  then  be  broken 
by  prying  outward  and  downward.  Unless  the  basal  attachment  is  comparatively  narrow, 
the  line  of  fracture  will  be  uncertain.  It  may  break  at  the  line  desired,  or  it  may  extend 
far  inward  toward  the  body  of  the  sphenoid,  rupturing  the  middle  meningeal  artery  or  even 
the  cavernous  sinus.  It  is  a  better  plan  to  remove  first  a  small  button  with  the  circular 
trephine,  and  from  this  opening  to  separate  carefully  the  dura  and  enlarge  sufficiently  with 
the  rongeur  forceps.  The  extent  of  bone  to  be  removed  will  vary  with  the  difficulties  of 
satisfactory  inspection,  the  amount  of  hemorrhage,  and  the  displaceability  of  the  middle 
lobe.  The  base  of  the  opening  should  in  most  cases  extend  from  a  point  just  above  the 
external  auditors'  meatus  to  the  tip  of  the  lesser  sphenoidal  wing.  The  mallet  and  gouge 
should  never  be  used  either  in  making  the  trephine  opening  or  in  making  a  flap,  because 
the  pounding  necessary  jars  the  brain  to  an  extent  of  which  we  have  no  conception,  and  in 
some  individuals  adds  enormouslv  to  the  shock. 


88o  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

The  dura  mater  and  brain  are  next  separated  from  the  middle  fossa  toward  the  tip  of 
the  petrous  bone.  In  some  instances  this  may  be  accomplished  without  opening  the  dura  ; 
in  others  the  dura  will  unavoidably  be  torn  in  all  directions.  Separation  of  the  dura  may 
be  brought  about  by  means  of  the  finger,  a  blunt  instrument,  or  by  a  small  piece  of  gauze 
held  in  forceps  (Tiffany).  Hemorrhage  is  usually  slight  at  this  stage  of  the  operation, 
unless  the  middle  meningeal  artery  is  cut.  Injury  to  the  artery  in  making  the  trephine  but- 
ton can  with  care  be  avoided.  Occasionally,  however,  the  artery  is  deeply  placed  in  its 
long  groove  or  is  completely  covered  by  bone.  Under  these  circumstances,  by  no  amount 
of  skill  or  care  can  injury  to  the  artery  be  avoided.  Under  some  circumstances  lifting  the 
dura  will  tear  the  artery  ;  its  position  in  its  groove  will  prevent  ligation.  When  the  artery 
has  been  cut,  it  should  be  tied  as  near  the  foramen  spinosum  as  possible.  Brief  application 
of  hemostatic  forceps  with  such  a  lateral  curve  that  they  can  be  made  to  grasp  the  cut  end 
in  the  dura  will  usually  check  permanently  this  arterial  hemorrhage.  When  the  artery  has 
been  divided  in  its  deep  groove  or  the  abnormal  bony  foramen  just  mentioned,  bleeding 
may  be  checked  by  the  use  of  large  and  powerful  hemostatic  forceps,  between  the  blades 
of  which  the  artery  may  be  crushed  against  the  bone. 

The  chief  source  of  hemorrhage  in  this  operation,  however,  is  in  the  deeper  dissections 
— from  the  sinuses  of  the  dura  mater.  This  hemorrhage,  at  times  excessive,  unfortunately 
cannot  be  avoided,  no  matter  what  the  amount  of  skill  and  experience  or  what  the  method 
of  operating.  In  some  cases  the  flow  of  blood  will  be  so  great  that  further  manipulations 
will  be  impossible,  and  the  operation  will  require  two  stages.  A  general  ooze  may  be 
checked  with  gauze.  An  open  sinus,  compressed  with  the  fingers  for  a  few  minutes,  will 
usually  cease  bleeding.  Hemorrhage  may  be  so  abundant  and  persistent,  however,  as  to 
require  prolonged  gauze  packing,  or  even  ligation  of  the  external  carotid. 

If  the  dura  cannot  be  easily  separated  from  the  middle  fossa,  if  it  is  extensively  torn  and 
the  brain  exposed,  further  attempts  at  separation  should  be  abandoned.  Intradural  manipu- 
lations, though  perhaps  more  dangerous  than  extradural,  have  the  advantage  of  being  intelli- 
gently directed  with  reference  to  the  chief  dangers  of  the  operation — wounding  of  the  cavern- 
ous sinus,  laceration  of  the  brain,  and  wounding  of  motor  nerves  to  the  eye.  Moreover,  by 
this  method  the  nerve-roots  entering  the  ganglion  may  be  divided  between  it  and  the  pons, 
as  Horsley  has  demonstrated. 

As  soon  as  hemorrhage,  if  any  is  present,  has  ceased,  the  dura  mater  should  be  carefully 
lifted  from  the  middle  fossa  by  means  of  a  broad,  curved  spatula  or  by  the  fingers  of  an  assist- 
ant. In  the  subdural  operation  the  ganglion  maybe  started  from  its  bed  by  cutting  and  lift- 
ing the  second  and  third  divisions  as  they  enter  their  respective  foramina.  Perhaps  the  most 
efficient  plan  is  to  divide  the  third  branch  close  to  the  foramen  ovale,  the  second  at  the  for- 
amen rotundum,  to  dissect  the  two  backward,  separating  them  from  their  attachments.  The 
ophthalmic  nerve  may  then  be  separated  from  its  contiguous  structures  and  cut  at  the  sphe- 
noidal fissure.  This  separation  must  be  made  with  extreme  nicety,  to  avoid  injuring  the 
cavernous  sinus  and  the  motor  nerves  of  the  eye.  The  advisability  of  removing  the  oph- 
thalmic division  is  questioned  on  account  of  the  trophic  changes  likely  to  follow  in  the  eye, 
and  because  the  first  division  is  never  affected  alone,  though  it  may  be  involved  reflexly.1 

The  motor  root  of  the  fifth  division  should  be  left  intact  if  this  can  possibly  be  accom- 
plished. The  distal  attachments  of  the  ganglion  having  been  separated  and  the  ganglion 
lifted  from  its  bed,  the  connection  with  the  brain  should  be  severed  close  to  the  dura  mater. 
If  the  dura  mater  has  been  opened,  the  sensory  filaments  connecting  the  ganglion  with  the 
pons  may  be  divided.  If  there  is  oozing  after  reasonable  delay  in  packing  in  the  depth  of 
the  operative  field,  a  small  gauze  wick  should  be  left  for  twenty-four  or  forty-eight  hours. 
In  some  instances  there  will  be  so  much  hemorrhage  that  the  depths  of  the  wound  will 
require  packing. 

The  surgeon  who  proposes  to  perform  this  operation  upon  the  living  should  practise  it 
upon  the  cadaver  until  he  can  expose  and  remove  the  Gasserian  ganglion  without  wounding 
the  artery,  the  cavernous  sinus,  or  the  nerves  supplying  the  eye. 

Harvey  Gushing  has  described  a  modification  of  the  Krause-Hartley  method  in  which 
the  manipulations  are  carried  out  in  the  arch  beneath  the  middle  meningeal  artery.  The 
essential  point  in  Cushing's  method  is  the  manner  of  finding  the  ganglion.  The  dura  mater 
is  separated  back  to  the  foramen  rotundum  and  the  foramen  ovale.  The  ganglion  lies  be- 
tween two  layers  of  the  dura  mater,  and  is  exposed  by  the  incision  into  this  dural  compart- 
ment. The  sensory  root  is  then  avulsed,  and  the  three  branches  cut  as  they  pass  into  their 
respective  foramina. 

The  immediate  dangers  of  the  operation  arise  from  hemorrhage  and  shock ;  remote 
dangers  are  meningitis  and  superficial  abscess.  A  disagreeable,  but  unavoidable  feature 
is  the  trophic  change  liable  to  occur  in  the  eye  of   the  affected  side,  with  loss  of  sight. 

As  a  relief  from  the  distressing  pain  of  a  trifacial  neuralgia,  this 
operation  gives  better  and  more  lasting  results  than  any  other.     Because 

1  Tiffany,  Annals  of  Surgery,  1896,  vol.  xxiv. ,  p.  584. 


MUSCULAR   SPASM.  88 1 

of  its  dangers  and  disadvantages,  however,  it  is  justly  characterized  as 
the  "operation  of  last  resort."  According  to  Tiffany1  the  mortality 
was  24  in  108  cases — 22  per  cent. — the  chief  causes  of  death  being 
shock  (8  cases)  and  sepsis  (8  cases).  "  Relief  of  pain  certainly  follows 
temporarily,  and  sometimes  permanently ;  but  it  may  recur  "  (Tiffany). 
Neuralgias  affecting  the  brachial  plexus  or  its  branches  occa- 
sionally cause  obstinate  and  unbearable  pain.  An  ascending  neuritis 
starting  in  a  peripheral  branch  and  finally  involving  the  brachial  plexus 
may  have  required  successively  stretching  or  avulsion  of  the  branch 
originally  affected,  stretching  of  the  brachial  plexus,  amputation  of  the 
hand,  of  the  forearm,  of  the  upper  arm,  or  even  of  the  arm  at  the  shoul- 
der. According  to  Abbe,2  such  neuralgias  may  accompany  ascending 
neuritis,  hemiplegia,  herpes  zoster,  and  allied  conditions,  as  well  as  car- 
cinoma. They  may  start  in  the  bulbous  ends  of  nerves  or  in  amputa- 
tion stumps.  Even  the  most  drastic  measures  often  fail.  As  a  last 
resort  the  posterior  nerve-roots  may  be  divided  within  the  spinal  dura. 

Abbe's  3  method  of  dividing  the  posterior  nerve=roots  is  as  follows:  "The 
region  from  which  the  affected  nerves  make  their  exit  from  the  cord  having  been  determined, 
a  long  incision  is  made  on  one  side  of  the  spinous  processes,  the  incision  being  carried 
rapidly  down  to  the  laminae.  The  spinous  processes  are  next  cut  through  at  their  base  with 
bayonet-shaped  cutting  pliers,  leaving  the  interspinous  ligaments  intact.  These  processes, 
with  the  muscles  attached,  are  retracted  well  to  the  other  side.  The  lamina;  are  then 
gnawed  away  with  rongeur  forceps  from  the  transverse  processes  to  the  base  of  the  spinous 
processes.  The  dura  is  exposed  and  opened  the  full  length  of  the  incision,  allowing  about 
2  or  3  drams  of  cerebrospinal  fluid  to  escape.  The  cord  is  then  pulled  to  the  side  of 
the  canal,  and  the  roots  picked  up  by  a  blunt  hook.  From  %.  to  y^  inch  of  nerve  is  excised. 
The  dura  is  sutured  with  fine  catgut,  and  the  muscles  allowed  to  fall  back  into  place." 
Keen  advises  destruction  of  the  ganglion  also. 

Neuralgia  of  the  Lower  Extremity. — Painful  affections  of  the 
lower  extremity  may  be  treated  like  those  of  the  upper.  In  the  event 
of  failure  the  distressing  symptoms  may  require  division  of  the  pos- 
terior nerve-roots  in  the  lumbar  or  the  sacral  portion  of  the  cord. 

Neuralgias  dependent  upon  injury,  upon  the  contraction  of  cicatri- 
cial tissues,  upon  entanglement  in  new  growths,  may  affect  any  sensory 
nerve.  The  surgical  treatment  is  the  same  as  that  already  outlined — 
disentanglement  from  the  exciting  cause  by  stretching,  neurectomy, 
removal  of  the  tumor  or  of  the  cicatrix. 

Neuralgias  involving  nerves  or  groups  of  nerves  other  than  those 
considered  above  are  met  with  occasionally.  The  same  principles  of 
treatment  apply  (see  Special  Nerves). 

MUSCULAR   SPASM. 

The  surgical  treatment  of  muscular  spasm  is  chiefly  that  of  Spas- 
modic wry-neck.  The  etiology  of  this  obscure  affection  is  so  uncer- 
tain that  treatment,  in  the  absence  of  definite  indications,  must  be 
symptomatic.  Spasmodic  wry-neck  demands  surgical  intervention 
only  when  all  rational  palliative  methods,  such  as  rest,  fixation,  mas- 
sage,  gymnastics,    electricity,    and    drugs,    have    failed.      The    results 

1  Annals  of  Surgery,  1896,  vol.  xxiv. ,  p.  585. 

2  Boston  Med.  and  Surg.  Jow .,  Oct.,  1896,  p.  329. 

3  Ibid.,  1S96,  vol.  cxxxv.,  p.  329. 

5fi 


882  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

of  operation  upon  the  spinal  accessory  nerve,  of  neurotomy  and  neu- 
rectomy, of  nerve-stretching  and  nerve-avulsion,  are  on  the  whole 
encouraging — the  more  destructive  the  operation,  the  more  lasting  the 
benefit.  Unfortunately,  the  immediate  quieting  of  the  sternomastoid 
and  the  trapezius — the  muscles  chiefly  affected — is  followed  in  many 
cases,  sooner  or  later,  by  spasmodic  contractions  of  other  muscles  of 
the  neck,  usually  the  posterior  rotators  of  the  head  on  the  opposite  side. 
In  the  majority  of  cases,  therefore,  operation  upon  the  spinal  accessory 
nerve  must  be  followed  by  operation  upon  the  nerves  supplying  these 
muscles — in  not  a  few  cases  neurectomy  being  associated  with  division 
of  the  muscles  themselves. 

In  the  simplest  form  of  spasmodic  wry-neck  the  head  is  tilted  for- 
ward and  rotated  by  the  sternomastoid.  In  the  common  extension  of 
spasm  to  the  posterior  rotators  of  the  other  side  previously  mentioned, 
rotation  occurs  in  the  same  direction,  but  the  head  is  drawn  back  rather 
than  tilted  forward,  through  the  greater  power  of  the  posterior  rotators, 
which  are  also  retractors.  In  exceptional  cases  the  head  is  drawn 
directly  backward  by  the  posterior  muscles  of  both  sides  acting  simul- 
taneously (retroco/tis).  In  a  still  rarer  form  the  head  is  drawn  directly 
forward  by  the  combined  action  of  the  two  sternomastoids.  An  occa- 
sional instance  is  seen  of  combined  action  of  the  sternomastoid  of  one 
side  with  the  posterior  rotators  of  the  same  side,  the  head  being  in  this 
event  drawn  directly  toward  the  shoulder.  In  many  cases  the  spasm 
can  be  controlled  by  continuous  effort ;  in  others  it  is  beyond  control. 
The  spasm  may  recur  constantly  and  violently  or  infrequently  and 
mildly.  Though  palliative  treatment  may  afford  relief,  many  cases 
yield  only  to  operation.  (For  the  etiology,  the  symptomatology,  and 
the  medical  treatment,  the  reader  is  referred  to  works  upon  Neurology.) 
The  muscles  affected  can  be  determined  by  the  position  of  the  head  and 
by  palpation  during  the  spasm.  The  sternomastoid  and  the  trapezius 
will  be  seen  in  spasmodic  action  of  varying  frequence  and  violence. 

Operations  on  the  Spinal  Accessory  Nerve. — The  spinal  accessory  nerve  can 
be  exposed  best  at  the  point  at  which  it  crosses  the  upper  part  of  the  neck  before  enter- 
ing the  sternomastoid.  It  proceeds  downward  and  outward  from  the  jugular  foramen, 
and  first  touches  the  anterior  border  of  the  sternomastoid  at  a  point  about  %  inch  01 
more  from  the  tip  of  the  mastoid  process.  An  incision  from  I  to  2  inches  in  length 
should  be  made  along  the  upper  part  of  the  anterior  border  of  the  sternomastoid.  The 
dissection  is  carried  directly  backward  toward  the  vertebral  bodies.  The  nerve  lies  more 
or  less  concealed  in  fascia,  but  can  usually  be  seen  if  the  dissection  is  bloodless.  Its 
position  may  be  felt  by  drawing  the  end  of  a  scalpel  handle  or  the  finger-nail  down- 
ward and  forward  over  its  probable  position.  As  the  instrument  or  the  nail  snaps  over 
the  nerve  the  sternomastoid  and  trapezius  will  contract.  Once  isolated,  it  may  be  stretched 
or  divided,  resected  or  avulsed.  The  most  satisfactory  method  is  to  remove  at  least  an 
inch  of  it.  The  wound  heals  rapidly,  and  the  immediate  effect  of  the  operation  is  gener- 
ally favorable. 

In  many  cases  the  spasm  is  not  completely  relieved,  though  the 
sternomastoid  and  trapezius  are  at  once  relaxed.  As  an  accessory  aid 
the  head  may  be  immobilized  for  a  few  days  after  the  operation.  In 
many  cases,  however,  the  spasm  appears  in  other  groups  of  muscles, 
usually  the  posterior  rotators  of  the  other  side. 

Of  the  operations  upon  the  posterior  rotators,  Keen's  oper= 
ation,1   based  entirely   upon  anatomical   lines,  seems  to   be  the  most 
satisfactory.     The  following  description  is  taken  from  Keen's  article : 
'  Annals  of  Surgery,  1891,  vol.  xiii.,  p.  44. 


MUSCULAR   SPASM. 


883 


The  first  step  in  the  operation  consists  in  a  3-inch  incision  across  the  neck,  starting  from 
the  median  line,  at  a  level  ^4  inch  below  the  lobe  of  the  ear.  This  incision  is  carried 
through  the  trapezius  and  posterior  border  of  the  splenius  capitis.  The  trapezius  is  then 
dissected  free  from  the  complexus,  above  and  below,  until  the  intramuscular  aponeurosis, 
usually  %  inch  below  the  incision,  is  found.  The  occipitalis  major  is  usually  found 
between  this  aponeurosis  and  the  median  line.  The  complexus  is  now  divided,  follow- 
ing the  occipitalis  carefully  as  a  guide.  This  nerve  is  freed  to  its  origin  from  the  second 
cervical  nerve.  A  section  of  the  trunk  of  the  posterior  division  of  the  second  cervical 
nerve,  between  the  occipitalis  major  and  the  spine,  is  removed  in  order  to  reach  the  filament 
from  this  region  to  the  inferior  oblique  muscle.  Next  is  found  the  inferior  oblique  muscle, 
to  which  the  occipitalis  nerve  is  a  guide  as  it  swings  around  the  lower  border  of  it.  Above 
this  muscle-is  the  suboccipital  triangle,  in  which  the  suboccipital  nerve  will  be  found  close 
to  the  occipital  bone  and  in  close  proximity  to  the  vertebral  artery. 

Again  starting  from  the  occipitalis  major  and  dissecting  up  the  complexus,  the  external 
branch  of  the  posterior  division  of  the  third  cervical  nerve  will  be  found  about  I  inch 
below.  This  nerve  is  to  be  divided  close  to  the  main  trunk  and  a  piece  excised.  If  it  is 
desired,  the  muscles  can  now  be  sutured  with  buried  catgut  sutures.  The  wound  is  then 
closed  (Keen). 

It  is  not  essential,  however,  to  suture  the  divided  muscle  ;  for  the  very  division  of  the 
muscles  is  quite  as  important,  at  least  in  some  cases,  as  the  division  of  the  nerves.  In  one 
instance  the  writer  divided  not  only  all  the  nerves  mentioned  above,  but  also  every  muscle 
from  the  external  occipital  protuberance  to  the  sternoclavicular  joint.  In  this  case  a 
perfect  cure  resulted,  although  the  spasm  had  been  excessive  and  accompanied  by  perma- 
nent shortening  of  the  whole  group,  with  marked  lateral  deformity. 

Other  muscular  groups  may  be  the  seat  of  spasm.  (For  the  consideration  of  these  the 
reader  is  referred  to  Special   Nerves. ) 


NERVE-TUMORS. 

Neuromata,  single  or  multiple,  are  not  uncommon.  True  neuro- 
mata composed  of  nerve-tissue  are  extremely  rare,  but  have  been 
observed.  Tumors  made  up  of  other  than  nerve-tissue  are  not  infre- 
quent.   Such  neoplasms  may  be  intimately  incorporated  with  the  nerve- 


.< 


Fig.  438. — Neuroma  after  amputation.  At  the  right  are  normal  nerve-fibers  passing 
into  a  bulbous  enlargement  containing  some  myelin-fibers  and  much  connective  tissue  (stain, 
Weigert;  oc.   1,  obj.   1,  Leitz).     (From  specimen  supplied  by  E.  W.  Taylor.) 

bundles  or  they  may  be  loosely  attached  to  them.  The  most  frequent 
are  the  fibromata  (Figs.  438,  439) ;  sarcomata  (Fig.  440)  and  myxomata 
are    occasionally  seen ;    but   carcinomata,  gliomata,  and    degeneration 


884 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


cysts  are  very  rare.     In  the  multiple  neuromata  the  tissue  is  usually 
fibrous,  though  there  may  be  other  and  malignant  forms  ;  moreover, 


Fig.  439. — Nerve-neuroma.  Rounded  tumors  connected  with  the  nerve-trunks  close  to 
their  cut  ends.  Man  aged  eighteen.  Amputation  of  arm  nine  years  before.  Severe  pain. 
(Warren  Museum,  Harvard  Medical  School.) 

different  varieties,  benign  and  malignant,  may  exist  in  the  same  indi- 
vidual. 

The  symptoms  of  neuromata  vary.  First  there  is  usually  pain 
along  the  course  of  the  affected  nerve.     The  nerve-functions  become 


Fig.  440. — Sarcoma  of  left  sciatic  nerve  ;  resection,  neuroplasty ;  restoration  of  function  almost 
complete  ;  no  recurrence  up  to  1902  (Richardson). 

interfered  with  and  impaired.  Anesthesia,  loss  of  power,  and  complete 
cessation  of  function,  with  trophic  changes,  may  ensue.  The  tumor 
is  painful  and  sensitive.     The  nerve-trunk,  unless  in  some  fixed  ana- 


LESIONS   OF  SPECIAL   NERVES.  885 

tomic  position,  like  that  of  the  ulna  at  the  internal  condyle,  allows 
the  tumor  to  be  freely  moved  laterally,  but  not  at  all  longitudinally. 
In  multiple  fibromata  the  brain  and  spinal  cord,  the  cranial  and  spinal 
nerve-roots,  the  ganglia,  the  plexuses,  and  the  peripheral  trunks  may 
be  extensively  involved.  Widely  separated  trophic  changes,  interfer- 
ences with  nutrition,  bed-sores,  and  fatal  marasmus  follow  in  more  or 
less  regular  sequence. 

Treatment. — For  single  neuromata  excision  is  the  only  rational 
treatment.  In  benign  neoplasms  palliative  treatment  is  permissible, 
though  for  complete  relief  excision  is  indicated  sooner  or  later  ;  in 
malignant,  immediate  excision  is  demanded,  chiefly  for  the  preserva- 
tion of  life.  Even  in  tumors  apparently  benign,  the  impossibility  of 
exact  diagnosis  makes  exploration  the  safer  plan.  Furthermore,  these 
symptoms,  caused  by  a  tumor  of  any  kind — benign  or  malignant — 
can,  as  a  rule,  be  effectually  relieved  only  by  removal  of  the  tumor 
itself.  Benign  neoplasms  not  intimately  caught  among  nerve-trunks 
should  be  dissected  out  with  as  little  injury  to  the  nerve-bundles  as 
possible.  If  separation  is  impossible,  the  nerves  should  be  cut  above 
and  below  the  growth,  the  growth  removed,  and  the  nerve-ends 
united.  Before  the  nerve  is  cut  it  should  be  thoroughly  stretched. 
Malignant  tumors  involving  nerves  should  be  removed  by  complete 
nerve-section,  unless  their  connection  with  nerve-trunks  is  such  that 
thorough  dissection  is  possible.  Encapsulated  sarcomata,  incorporated 
with  important  nerves,  but  easily  separated  from  the  nerve-bundles, 
may  be  carefully  removed.  In  cases  of  doubt  the  nerve  and  tumor 
should  be  resected.  When  several  accessible  tumors  exist,  involving 
one  or  more  nerves,  all  may  be  excised.  The  usual  form  of  multiple 
neuromata  admits  of  no  surgical  treatment. 

Bulbous  nerves  in  amputation  stumps  are  composed  chiefly  of 
fibrous  tissue,  in  which  the  nerve-bundles  may  become  compressed, 
giving  rise  to  pain.  In  some  instances  an  ascending  neuritis  may 
follow,  and  require  section  of  the  posterior  nerve- roots  in  the  spinal 
canal.  The  bulbous  ends  can  generally  be  felt  in  the  amputation 
stump  as  painful,  tender  tumors.  The  bulbous  end  of  the  nerve  should 
first  be  completely  isolated  by  clean  dissection.  It  should  then  be 
grasped  between  layers  of  dry  gauze,  and  the  nerve  thoroughly 
stretched.  The  tumor  is  now  removed  by  division,  with  a  sharp  knife, 
with  an  inch  or  more  of  healthy  nerve.  Bulbous  nerves  for  the  same 
reason  that  they  first  appeared,  are  likely  to  recur.  It  is  important  in 
amputating  to  avoid  including  in  the  ligation  of  arteries  the  nerve  or 
any  of  its  filaments,  especially  if  a  non-absorbable  ligature  is  used. 
Though  it  has  not  been  demonstrated  that  compression  of  a  cut  nerve- 
end  by  a  non-absorbable  ligature  is  a  cause  of  bulbous  nerves,  yet  the 
possibility  of  such  causation  should  be  borne  in  mind  and  the  con- 
tingency avoided. 

LESIONS  OF  SPECIAL  NERVES. 

Injury  to  the  olfactory  nerve,  by  fracture  through  the  cribriform  plate  of  the  ethmoid, 
may  result  in  permanent  impairment  of  the  sense  of  smell. 

The  Optic  nerve  may  be  compressed  by  retrobulbar  neoplasms  or  by  inflammatory 
exudations.  Impairment  of  sight  may  gradually  follow  excessive  pressure,  the  nerve  suc- 
cessfully withstanding  extraordinary  elongation  or  elevation.      Fracture  through  the  lessei 


886  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

wing  of  the  sphenoid  may  destroy  completely  the  functions  of  the  nerve.  Pressure  from 
orbital  tumors  and  exudates  should  be  relieved,  if  possible,  by  dissection  or  by  drainage. 
The  orbital  cavity  may  be  approached  by  removal  of  the  external  angle  of  the  frontal 
bone.      When   the  nerve  has  been  ruptured  by  fracture,  nothing  can  be  done. 

The  third,  fourth,  and  sixth  nerves,  from  their  course  along  the  cavernous  sinus, 
maybe  involved  in  fractures  of  the  base  of  the  sphenoid;  they  may  be  compressed  by 
new  growths;  the  sixth  is  especially  liable  to  injury  during  operations  upon  the  Gasserian 
ganglion.  Accidental  wounding  of  the  nerves  by  operation  has  not,  however,  been 
recorded.  Nevertheless,  intracranial  dissection  of  the  ganglion  should  be  made  with  great 
care,  to  avoid  these  important  structures. 

The  auditory  nerve  may  suffer  through  fractures  or  wounds  of  the  petrous  portion 
of  the  temporal.  A  case  has  recently  come  under  the  author's  observation  in  which  an 
accidental  gunshot-wound,  piercing  the  meatus,  destroyed  entirely  the  sense  of  hearing. 
Whether  this  was  owing  to  injury  to  the  structures  of  the  middle  ear  it  was  impossible  to 
say.      Removal  of  the  bullet  was  not  followed  by  any  improvement  in  hearing. 

The  facial  nerve  may  be  injured  anywhere  in  its  course  through 
the  temporal  bone.  It  is  peculiarly  liable  to  injuries  during  operations 
upon  the  face.  Facial  paralysis  following  severe  injury  to  the  skull 
always  suggests  a  fracture  somewhere  through  the  temporal  bone,  with 
bruising,  laceration,  or  total  destruction  of  the  nerve.  A  facial  paral- 
ysis accompanying  inflammation  of  the  middle  ear  portends  extension 
of  the  process  into  the  mastoid  cells,  or  at  least  pressure  of  an  exudate 
somewhere  in  the  course  of  the  nerve,  either  as  it  crosses  the  vault  of 
the  tympanum  or  in  the  mastoid  itself.  This  nerve  is  also  involved  in  cer- 
tain neoplasms  of  the  parotid,  especially  infiltrating  carcinomata.  The 
nerves,  strangled  by  the  density  of  the  growth,  may  be  found  infiltrated 
with  cancer  cells.  In  this  form  of  facial  paralysis  the  compression  comes 
on  gradually.  It  is  total,  and,  from  the  nature  of  the  surrounding  tumor, 
cannot  be  successfully  relieved ;  for  it  is  essential  in  such  cases,  if  any 
attempt  is  made  at  thorough  removal,  to  take  out  the  whole  growth 
by  as  wide  a  margin  of  sound  tissue  as  possible,  and  in  this  dissection 
the  nerve  is,  of  course,  sacrificed.  Acute  parotitis  may,  though  infre- 
quently, cause  facial  paralysis.  The  facial  nerve  is  perhaps  more  fre- 
quently associated  with  muscular  spasm  than  any  other,  excepting  the 
spinal  accessory.  Whether  the  nerve  merely  transmits  the  central  irri- 
tation, or  is  itself  the  seat  of  irritation,  cannot  be  determined  any  more 
positively  than  in  spasmodic  wry-neck. 

Facial  paralysis  occurring  suddenly  in  persons  of  good  health, 
usually  supposed  to  be  owing  to  the  effect  of  cold  or  exposure,  is 
probably  caused  by  pressure,  either  postural  during  sleep,  or  from  some 
other  source. 

Treatment  of  Facial  Paralysis. — The  treatment  of  facial  paralysis 
from  the  causes  mentioned  is  discouraging.  Nothing  surgical  can  be 
done  for  these  paralyses  dependent  upon  causes  within  the  bony  canal, 
unless  they  are  produced  by  inflammatory  exudations  in  the  mastoid, 
in  which  case  they  may  be  relieved  by  trephining  and  drainage.  Para- 
lysis caused  by  the  constriction  of  new  growths  gives  little  hope  of 
relief,  unless  the  growth  is  benign,  when  the  nerve  may  be  dissected 
from  the  growth  or  the  growth  from  the  nerve.  In  carcinoma  such  a 
method  of  relief  is  impracticable.  Tumors  that  do  not  surround  and 
constrict  the  nerve  rarely,  if  ever,  cause  trouble.  The  commonest 
tumor  of  the  parotid — the  enchondroma — may  attain  enormous  size 
without    affecting    the    nerve-function.       More    paralyses    result    from 


LESIONS   OF  SPECIAL    NERVES.  887 

cutting  the  nerve  in  removing  these  large  growths  than  occur  in  the 
natural  development  of  them. 

The  facial  may  be  exposed  in  the  mastoid  by  chiselling,  in  those  rare 
instances  in  which  such  an  operation  is  desirable.  It  may  be  isolated 
at  the  stylomastoid  foramen  and  followed  back  through  the  aquaeductus 
Fallopii. 

Treatment  of  Facial  Spasm. — No  surgical  treatment  has  been 
used  until  recently  except  stretching  of  the  nerve.  The  nerve  is 
exposed  at  the  anterior  border  of  the  parotid  or  in  the  parotid  itself. 
If  but  one  division  is  affected,  the  nerve  may  be  sought  in  front  of  the 
parotid ;  if  the  whole  nerve,  it  may  be  exposed  in  the  parotid  gland, 
about  a  finger's  breadth  below  the  lobule  of  the  ear.  It  may  be 
exposed  behind  the  parotid,  between  the  sternomastoid  and  the  stylo- 
mastoid foramen,  according  to  Bonner's  method.  By  this  method  the 
resulting  scar  is  inconspicuous.  The  nerve  may  be  stretched  upon  the 
finger  as  upon  a  bent  hook.  It  will  bear,  post  mortem,  between  5  and 
10  pounds ;  but  less  force  should  be  used  in  life.  In  many  instances 
the  spasm  is  associated  with  neuralgia  of  the  corresponding  trifacial 
terminals.  Relief  of  the  trifacial  pain  will  be  followed  by  cessation  of 
spasm.  For  facial  spasm  unattended  by  pain  the  facial  nerve  has  been 
stretched,  with,  however,  but  transitory  benefit  or  with  no  benefit  what- 
ever. In  some  instances  temporary  facial  paralysis  has  followed  the 
operation.  It  has  recently  been  suggested  that  facial  spasm  may  be 
relieved  by  supplying  artificial  anastomosis  between  the  spinal  acces- 
sory and  facial  nerves. 

The  glossopharyngeal  nerve  has  no  surgical  importance,  though  frequently  paralyzed 
as  the  result  of  diphtheria  ;  and  though,  like  all  other  nerve-structures,  it  may  be  injured, 
its  deep  situation  gives  it  no  especial  surgical  interest. 

The  pneumogastric  nerve  may  be  involved  in  neoplasms  of  the 
neck  ;  it  may  be  compressed  or  dislocated  by  them  ;  it  may  be  com- 
pressed in  deep  cervical  abscess  ;  it  may  be  divided  in  deep  wounds  of 
the  neck ;  it  may  be  injured  accidentally  in  deep  operations  upon  the 
neck  ;  or  it  may  be  deliberately  resected  in  the  removal  of  infiltrating 
cervical  tumors.  The  symptoms  caused  by  section  of  the  vagus  vary. 
In  cases  collected  by  Park,1  dyspnea,  dysphagia,  slow  respiration  with 
laryngismus  and  alteration  of  voice,  reduced  respiratory  murmur  of  the 
affected  side,  asthma,  pneumonia,  etc.,  were  observed.  When  both  pneu- 
mogastric  nerves  were  affected  by  the  pressure  of  tumors,  there  were 
present  lung-disturbances,  dyspnea,  depression  of  pulse,  and  ravenous 
appetite.  In  48  cases  in  which  the  nerve  was  cut,  21  died  and  27 
recovered.  In  the  fatal  cases  it  was  impossible  to  say  that  death  was 
caused  by  the  lesion  alone. 

Section  of  the  pneumogastric  does  not  necessarily  mean  death  ;  but 
operation  should  not  be  prolonged  after  division,  and  the  nerve  should, 
if  possible,  be  immediately  sutured.  The  pneumogastric  nerve  may  be 
exposed  by  a  longitudinal  incision  in  the  neck  along  the  anterior 
border  of  the  sternomastoid  muscle.  It  will  be  found  behind  and  be- 
tween the  carotid  artery  and  the  jugular  vein,  in  the  same  sheath  with 
them. 

Affections  of  the  recurrent  laryngeal  branch  of  the  pneumogastric 

1  Trans.  Am.  Surg.  Assoc,  vol.  xiii.,  p.  253. 


SSS  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

nerve  are  more  frequent  than  those  of  the  trunk.  This  nerve,  on  one 
or  both  sicks,  is  occasionally  involved  in  tumors — malignant,  benign,  or 
aneurysmal — of  the  deep  neck,  or  of  the  mediastinum,  of  the  esophagus, 
the  trachea,  or  the  thyroid.  It  may  be  injured  by  the  impaction  of  foreign 
bodies  in  the  esophagus,  or  compressed  by  deep  cervical  abscesses;  it 
may  be  injured  in  the  removal  of  thyroid  tumors  or  in  the  ligation  of 
the  inferior  thyroid  arteries.  Paralysis  of  the  recurrent  laryngeal  nerve 
results  in  interference  with  the  voice  and  may  cause  spasm  of  the 
glottis  and  dyspnea.  Symptoms  of  recurrent  laryngeal  involvement 
may  aid  in  the  diagnosis  and  localization  of  tumors  and  of  foreign 
bodies.  The  results  of  such  involvement  may  produce  the  most 
alarming  symptoms  of  impeded  inspiration,  and  may  require  immediate 
tracheotomy. 

The  treatment  of  laryngeal  spasm  requires  tracheotomy  or  intu- 
bation, after  which  permanent  relief  of  the  dyspnea  may  be  accomplished 
by  operation  upon  the  recurrent  laryngeal  and  removal,  if  possible,  of 
the  compressing  tumor.  In  the  case  of  pressure  by- a  deep  cervical 
abscess  or  by  a  foreign  body,  the  abscess  should  be  opened  or  the 
foreign  body  removed.  In  many  instances  the  effects  of  pressure  or 
of  irritation  are  transitory ;  in  others  they  are  permanent. 

The  spinal  accessory  may  require  surgical  treatment  in  connec- 
tion with  spasmodic  wry-neck  (q.v);  it  maybe  injured  accidentally; 
it  may  be  removed  or  resected  in  the  removal  of  tumors  deeply  situ- 
ated under  or  beyond  the  sterno-mastoid  muscle.  The  cutting  of  this 
nerve  produces  no  serious  symptoms.  The  muscles  supplying  the 
sternomastoid  and  trapezius  soon  regain  their  tone  through  collateral 
branches  of  the  cervical  plexus  or  of  the  spinal  nerves.  This  restor- 
ation of  muscle  power  may  account  for  the  restoration  of  spasm  so 
often  seen  after  division  of  the  spinal  accessory  nerve  in  spasmodic 
wry-neck,  and  is  an  argument  in  favor  of  a  central,  rather  than  a 
peripheral,  origin  for  this  affection. 

The  hypoglossal  nerve  may  be  injured  by  gunshots,  cuts  in  the  throat,  in  operations 
upon  submaxillary  tumors  and  upon  the  tongue.  The  division  of  this  nerve  produces  a 
deviation  of  the  tongue  toward  the  affected  side.  Though  injury  to  the  hypoglossal  nerve 
does  not  seriously  impair  the  functions  of  the  tongue,  the  nerve  should  be  sutured  when- 
ever possible  after  accidental  or  intentional  division. 

The  hypoglossal  nerve  may  be  exposed  through  a  curved  incision  along  the  lower 
border  of  the  submaxillary  triangle.  It  will  be  found  resting  upon  the  hyoglossus  muscle, 
close  to  the  angle  made  by  the  tendon  of  the  two  bellies  of  the  digastric  muscle,  with 
which  angle  it  makes  a  small  triangle,  containing,  deep  in  the  fibers  of  the  hyoglossus, 
the  lingual  artery. 

Cervical  Plexus. — Of  the   cervical   plexus  the  phrenic  nerve  is 

most  important  from  the  surgical  point  of  view.  The  nerve  may  be 
injured  in  operations  and  in  accidental  wounds  of  the  neck.  Its  posi- 
tion with  reference  to  the  scalenus  anticus  muscle,  to  the  common 
carotid,  subclavian,  and  innominate  arteries,  and  jugular,  innominate, 
and  subclavian  veins,  should  be  carefully  borne  in  mind  in  deep  cervical 
dissection.  The  phrenic  nerve  is  most  liable  to  operative  injuries  in  the 
removal  of  deep  cervical  tumors,  especially  those  in  close  relation  with 
the  scalenus  anticus  muscle — benign  and  malignant  adenomata,  ad- 
herent thyroid  tumors,  and  the  like.  This  nerve,  like  the  pneumogas- 
tric,  is  so  conspicuous  a  landmark  in  the  deep  neck  that  neither  is  likely 
to  be  injured   in   the   careful   dissection   of   normal   anatomy.     When 


LESIONS   OF  SPECIAL    NERVES.  889 

injuries  do  occur,  they  are  the  result  of  deviations  from  the  normal 
relations  by  pressures  or  entanglement  and  concealment  by  infiltrations. 
The  symptoms  are  not  usually  immediate ;  they  are  interference  with 
respiration,  incessant  coughing,  purulent  bronchitis,  congestion  of  the 
lungs,  and  pneumonia.  Of  8  cases  collected  by  Park,1  2  recovered. 
In  the  recoveries  it  is  not  clear  that  the  phrenic  was  actually  divided. 
Accidental  division  should  be  followed  by  immediate  suture. 

Other  branches  of  the  cervical  plexus  may  be  wounded,  and  often 
are  wounded  in  dissections  of  the  neck.  They  should  be  avoided  as 
much  as  possible  in  such  dissections,  though  when  thoroughness 
requires  it,  they  may  be  freely  sacrificed.  The  chief  objection  to  the 
cutting  of  these  nerves  is  an  anesthesia  which,  though  but  temporary, 
is  unpleasant,  and  an  occasional  neuralgia  from  entanglement  of  the 
cut  ends  in  the  scar. 

The  brachial  plexus  may  be  injured  by  direct  violence,  cuts, 
stabs,  by  pressure  upon  an  exostosis  of  the  first  rib,  by  pressure  of  a 
cervical  rib,  by  the  pressure  of  tumors,  by  the  immediate  bruising 
from  dislocation  of  the  head  of  the  humerus,  or  from  the  pressure  of 
crutches,  or  from  a  prolonged  Trendelenburg  position.  In  incised 
wounds  the  cut  ends  of  the  cords  of  the  plexus  should  if  possible  be 
united;  pressure  from  tumors,  exostoses,  or  the  other  causes  enumerated 
should  be  relieved.  The  most  prolific  cause  of  brachial  paralysis — 
dislocation  of  the  head  of  the  humerus — requires  immediate  reduction 
of  the  dislocation.  In  not  a  few  instances,  however,  the  dislocation 
remains  for  a  long  time  undiscovered.  When  reduction  of  old  disloca- 
tions is  attempted,  serious  and  permanent  injury  to  the  brachial  plexus 
may  be  caused  by  the  forcible  tearing  of  the  head  of  the  bone  from  a 
new  socket  closely  adherent  to  the  cords  of  the  plexus.  This  danger — 
with  that  of  tearing  open  axillary  artery  and  vein — makes  the  possible 
reduction  of  old  humeral  dislocations  especially  hazardous.  Reduction 
by  intelligent  dissection  is  in  reality  much  safer.  The  upper  portion 
of  brachial  plexus  may  be  exposed  above  the  clavicle  by  deep  dis- 
sections in  the  subclavian  triangle ;  the  lower  portion  by  high  axillary 
dissection. 

The  circumflex  nerve  has  special  importance  from  the  frequent 
paralysis  of  the  deltoid  caused  by  falls  upon  the  shoulder.  Such 
paralyses  usually  recover  spontaneously.  When  the  humerus  is  dis- 
located by  the  fall,  the  circumflex  nerve  may  be  torn,  and  paralysis 
may  be  permanent.  Massage,  passive  motion,  and  electricity  aid  in 
restoring  the  functions  of  the  nerve.  When  by  continued  paralysis  it 
seems  clear  that  the  nerve  has  been  torn,  its  divided  ends  may  be 
sought  for  and  sutured.  There  is,  however,  little  encouragement  that 
the  search  will  be  successful,  owing  to  the  small  size  of  the  nerve 
trunk  and  its  deep  situation.  The  musculospiral  nerve  is  more  fre- 
quently the  seat  of  injury  than  any  other  nerve.  It  is  often  caught 
between  fragments  of  a  broken  humerus  or  in  the  resulting  callus ;  it 
is  frequently  bruised  (Fig.  423)  by  direct  violence,  paralyzed  by  the 
temporary  compression  of  tourniquets,  or  the  edges  of  an  operating 
table.  The  nerve  is  exposed  by  an  oblique  incision  over  the  musculo- 
spiral groove  by  cutting  through  the  tendon  of  the  triceps. 

1  Loc.  cit. 


89O  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

The  musculocutaneous  nerve  before  it  enters  the  biceps  may  be 
injured  in  operations  about  the  shoulder-joint  or  the  axilla.  Injuries  to 
this  nerve  produce  paralysis  of  the  biceps  and  the  brachialis  anticus 
muscle.  In  venesections  of  the  median  cephalic  at  the  elbow  the  nerve 
may  be  directly  injured,  or  irritated  and  rendered  painful  by  the  pres- 
sure from  the  resulting  scar. 

The  ulnar  and  median  nerves  in  the  upper  arm  are  sometimes 
accidentally  divided  ;  sometimes  they  are  pressed  upon  by  tumors,  and 
sometimes  by  the  prolonged  application  of  the  elastic  tourniquet.  The 
ulnar  may  be  injured  in  excisions  of  the  elbow-joint  and  other  oper- 
ations in  the  vicinity  of  the  joint.  The  median  nerve  will  be  found  by 
an  incision  parallel  to  the  brachial  artery,  along  the  edge  of  the  biceps 
and  coracobrachialis ;  the  ulnar,  above  the  middle  of  the  arm,  will  be 
found  at  the  inner  side  of  the  brachial  artery.  As  the  nerve  approaches 
the  elbow  it  makes  straight  for  the  groove  behind  the  internal  condyle, 
where  it  is  firmly  fastened  by  a  sheath  of  fibrous  tissue. 

The  ulnar  nerve  in  the  forearm  and  the  wrist  is  more  com- 
monly injured  than  any  other  nerve;  the  median  less  commonly  than 
the  ulnar.  Injuries  to  the  ulnar  nerve  at  the  wrist  are  usually  the 
result  of  accidentally  incised  wounds.  The  ulnar  nerve  is  not  infre- 
quently injured  in  fractures  of  the  elbow  involving  the  internal  condyle. 
Temporary  paralysis  may  follow  long-continued  pressure  at  this  point. 
It  may  be  exposed  in  the  groove  behind  the  internal  condyle.  From 
the  internal  condyle  to  the  wrist  the  nerve  lies  between  the  superficial 
and  the  deep  flexors,  in  the  greater  part  of  its  course  lying  to  the 
median  side  of  the  flexor  carpi  ulnaris  muscle. 

The  median  nerve  may  be  exposed  at  the  bend  of  the  elbow, 
where  it  lies  in  close  relation  to  the  brachial  artery ;  between  the  bend 
of  the  elbow  and  the  middle  of  the  wrist  it  lies  between  the  superficial 
and  the  deep  flexors,  the  guide  to  it  at  the  wrist  being  the  tendon  of 
the  palmaris  longus.  If  that  muscle  be  absent,  it  may  be  found  lying 
superficially  among  the  flexor  tendons. 

Wounds  of  the  branches  of  the  ulnar  and  median  nerves  in 
the  hand  are  not  infrequent.  Unless  the  lesion  is  at  a  point  central 
to  the  distribution  of  the  muscular  branches,  no  operative  intervention 
is  indicated.  In  some  instances,  however,  section  of  the  terminal  sen- 
sory branches  may  cause  unpleasant  symptoms  and  may  justify  suture. 
Two  instances  of  this  kind  have  come  under  the  writer's  observation ; 
both  were  relieved  by  operation. 

The  posterior  interosseous  branch  of  the  musculospiral  may  be 
injured  in  serious  lesions  of  the  elbow-joint  and  in  excision  of  that 
joint.  This  nerve  may  be  avoided  by  giving  the  supinator  brevis  a 
wide  berth.  In  several  cases  of  fracture  of  the  lower  end  of  the 
humerus,  wrist-drop  has  been  caused  by  a  lesion  of  the  posterior  inter- 
osseous branch,  the  radial  being  uninjured. 

The  intercostal  branches  of  the  spinal  nerves  are  sometimes, 
though  rarely,  the  seat  of  neuralgias.  A  persistent  intercostal  neuralgia 
suggests  the  pressure  of  a  thoracic  aneurysm.  True  neuralgia  limited 
to  the  nerve,  not  associated  with  mediastinal  tumors,  may  justify 
excision  of  the  main  trunk  of  the  affected  nerve.  This  may  be  done 
by  an  incision  into  the  intercostal  space,  near  the  middle  of  which  the 


LESIONS   OF  SPECIAL   NERVES.  89 1 

nerve  usually  lies.  The  intercostal  and  other  nerves  supplying  the 
abdominal  muscles  may  occasionally  require  stretching  or  section  for 
abdominal  spasm.  One  such  case  has  occurred  in  the  writer's  expe- 
rience. 

The  nerves  of  the  lumbar  plexus — the  ilio-inguinal,  iliohypo- 
gastric, external  cutaneous,  and  genitocrural — have  a  passing  interest. 
Traumatic  lesions  are  usually  operative,  though  they  may  be  acci- 
dental. The  iliohypogastric  may  be  compressed  by  the  sutures  applied 
in  operations  for  movable  kidney.  This  nerve  in  its  course  passes 
along  the  border  of  the  quadratus  lumborum.  In  one  instance  at  least 
the  writer  has  met  with  a  most  painful  affection  of  this  nerve  from 
entanglement  in  the  fixation-ligatures  of  a  nephrorrhaphy.  The  ilio- 
inguinal and  the  iliohypogastric  may  also  be  injured  in  operations 
about  the  inguinal  canal  and  spermatic  cord.  Neuralgia  of  the  testicle, 
in  some  instances,  at  least,  may  be  relieved  by  neurectomy  of  the  ilio- 
inguinal or  the  genitocrural  branches  to  the  scrotum  and  testis.  Such 
an  operation  should  be  tried  for  the  relief  of  pain  before  orchidectomy 
is  resorted  to.  The  motor  nerves  of  the  lower  abdominal  muscles  are 
frequently  injured  by  incision  into  the  right  lower  abdominal  quadrant. 
Such  injuries  are  unavoidable  when,  as  in  acute  appendicitis,  cuts 
regardless  of  length  or  situation  are  demanded.  In  abdominal  emer- 
gencies which  require  long  incisions  through  muscles  nerves  must  be 
disregarded.  Impairment  of  muscular  power  more  or  less  severe,  com- 
plete, and  permanent  cannot  but  result.  Fortunately,  the  source  of 
motor  function  is  so  extensive  that  collateral  motor  supply  is  usually 
established.  It  is  important,  nevertheless,  in  abdominal  incisions  that 
the  motor  nerve  supply  be  as  far  as  possible  conserved. 

The  nerves  of  the  lower  extremities  may  be  the  seat  of 
serious  traumatism,  accidental  or  operative.  They  may  require  the 
same  general  principles  of  treatment  as  the  nerves  above  mentioned. 
The  anterior  crural  nerve  and  its  branches  can  be  exposed  by  a 
longitudinal  incision  beginning  at  the  middle  of  Poupart's  ligament  and 
extending  downward.  The  nerve  is  external  to  the  artery,  and  breaks 
up  to  supply  numerous  muscular  branches.  The  chief  sensory  branch — 
the  long  saphenous — passes  downward  over  the  internal  condyle  of 
the  femur,  and  is  distributed  over  the  inner  side  of  the  foot.  It  maybe 
exposed  anywhere  along  its  course. 

Of  the  sacral  plexus  the  sciatic  has  the  greatest  importance  from 
its  being  frequently  the  seat  of  intractable  pain.  From  the  great 
importance  of  this  compound  nerve,  stretching  rather  than  excision  is 
applicable  (see  Nerve-stretching).  Unfortunately,  stretching  rarely 
affords  permanent  relief  to  pain.  The  nerve  may  be  exposed  in  the 
posterior  region  of  the  thigh,  just  below  the  lower  border  of  the  gluteus 
maximus.  A  stretching  force  sufficient  to  lift  the  thigh  from  the  table 
may  be  applied,  the  patient  being  prone. 

The  popliteal  nerves  may  be  the  seat  of  painful  affections  from  the 
pressure  of  popliteal  tumors,  especially  aneurysms.  Relief  is  obtained 
by  removal  of  the  tumor  or  by  cure  of  the  aneurysm. 

The  anterior  tibial  nerve  may  be  injured  as  it  passes  round  the  head 
of  the  fibula,  being  there  subcutaneous.  The  nerve  may  be  exposed 
by  an  incision  through  the  skin  at  this  point.     Further  down  it  can  be 


892  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

found  between  the  tibialis  anticus  and  the  extensor  longus  digitorum. 
High  up  in  the  anterior  region  of  the  leg,  it  lies  between  the  extensor 
longus  pollicis  and  the  tibialis  anticus  muscle. 

The  posterior  tibial  may  be  exposed  by  section  of  the  soleus  from 
its  attachments  to  the  tibia  or  fibula.  By  elevating  that  muscle  the 
nerve  will  be  found  resting  upon  the  deep  muscles  of  the  calf.  At  the 
internal  malleolus  the  posterior  tibial  nerve  may  be  the  seat  of  trau- 
matisms, accidental  or  operative.  This  nerve  lies  posterior  to  the 
artery  at  this  point,  and  may  be  exposed  by  a  curved  incision  an 
inch  or  two  in  length. 

The  surgery  of  the  sympathetic  system  is  limited  to  the  cer- 
vical division  ;  injuries  to  the  great  plexuses  in  other  parts  of  the  body, 
such  as  the  celiac,  are  beyond  surgical  intervention.  The  cervical 
sympathetic  may  be  injured  by  deep  wounds  of  the  neck  and  in  deep 
operations  upon  the  neck  ;  it  may  be  pressed  upon  by  tumors  or  by 
deep  cervical  abscesses.  Abbe  1  reports  a  case  of  fibrosarcoma  of  the 
cervical  ganglia.  He  collected  43  cases  of  multiple  neuromata  in 
which   the   sympathetic   system   was   more   or  less   involved. 

The  symptoms  of  irritation  of  the  cervical  sympathetic  are  as  follows  : 
The  eye-slit  increases  in  width,  the  skin  of  the  neck  and  face  is  pale 
and  cold,  the  pupils  are  dilated,  the  eyes  sunken ;  the  sweat,  the  nasal 
secretion,  and  the  saliva  are  diminished.  Section  or  destruction  of  the 
nerve  gives  the  exact  reverse  of  these  symptoms. 

Surgery  of  the  sympathetic  at  the  present  time  has  its  widest  field 
in  operations  upon  the  cervical  ganglia  for  exophthalmic  goiter  and 
epilepsy.  These  operations  find  their  most  ardent  supporters,  however, 
among  the  French  surgeons.  Jonnesco  recommends  section  of  the 
cervical  sympathetics  in  exophthalmic  goiter,  epilepsy,  hysteria,  chorea, 
tumors  of  the  brain,  and  glaucoma. 

The  cervical  ganglia  may  be  reached  through  an  incision  at  the 
anterior  border  of  the  sternocleidomastoid,  beginning 'a  short  distance 
below  the  tip  of  the  mastoid.  The  ganglia  will  be  found  posterior  to 
the  great  vessels,  between  their  sheath  and  the  prevertebral  group  of 
muscles. 

For  exophthalmic  goiter  resection  of  the  nerve  or  of  one  or  both 
ganglia,  on  one  or  both  sides,  may  be  resorted  to.  For  epilepsy,  both 
the  upper  cervical  ganglia,  on  both  sides  of  the  neck,  including  the 
cords  connecting  them,  should  be  removed.  The  value  of  these  opera- 
tions has  not  yet,  however,  been  fully  demonstrated. 

1  Annals  of  Surgery,  1S98,  vol.  xxvii.,  p.  487. 


CHAPTER    XXVII. 
SURGERY  OF  THE  HEART  AND  BLOOD-VESSELS. 

HEART  AND  PERICARDIUM. 

The  surgery  of  the  heart  and  pericardium  is  advancing.  Pus  in  the 
pericardium  is  being  boldly  attacked  with  increasing  frequency,  and 
wounds  of  the  heart  have  been  several  times  closed  by  suture  with  suc- 
cessful issue. 

Here  and  there  in  the  current  literature  of  surgery  may  be  found 
carefully  reported  cases  of  direct  injury  to  the  heart  followed  by 
recovery,  and  the  deductions  from  these  cases  should  lead  surgeons  to 
bolder  methods  of  treatment  in  these  hazardous  cases.  For  example, 
in  the  index  catalogue  of  the  library  of  the  Surgeon  General's  Office, 
U.  S.  A.,  there  are  reported  22  cases  of  direct  injury  to  the  heart,  all 
of  which  lived  over  three  hours;  17  lived  over  three  days;  8  lived 
over  ten  days  ;  2  lived  over  twenty-five  days  ;  I  died  on  the  fifty-fifth 
day,  and  there  are  3  well-authenticated  recoveries. 

The  lesions  of  the  heart  and  pericardium  which  may  be  treated 
surgically  are  the  result  of  both  injury  and  disease,  and  they  comprise 
wounds  and  ruptures,  effusions  or  hemorrhages — often  resulting  in  dis- 
tention of  the  pericardium  and  pressure  on  the  heart.  Rupture  of  the 
heart  never  occurs  unless  the  heart-muscle  has  been  previously  weak- 
ened by  disease.  Traumatism  or  sudden  obstruction  of  the  coronary 
arteries  may  be  the  immediate  cause  of  rupture  of  the  heart  when  any 
predisposing  condition  exists.  It  is  a  calamity  usually  resulting  in 
immediate  death,  and  is  accompanied  by  intensely  severe  precordial 
pain.  In  case  the  rupture  is  a  small  one,  death  may  not  be  instan- 
taneous, and  life  may  be  prolonged  for  several  hours.  In  such  a  case 
a  diagnosis  might  be   made. 

The  following  quoted  cases  are  of  interest  in  this  connection  :  Hutchinson1  reports  a 
traumatic  rupture  of  the  heart  due  to  the  kick  of  a  horse  on  the  precordia.  The  patient 
lived  four  hours  after  the  injury,  and  at  the  autopsy  there  was  found  no  fracture  of  the  ribs 
or  sternum,  but  a  rupture  %  inch  in  length  at  the  apex  of  the  right  ventricle. 

Strassman "  records  the  case  of  a  man  of  sixty-five,  of  previously  good  health,  who  was 
kicked  in  the  chest. by  a  horse.  Signs  of  cardiac  insufficiency  soon  developed,  and  after  six 
months  he  died  of  cardiac  failure.  Necropsy  showed  a  rupture  of  the  intima  and  partial 
rupture  of  the  media  of  the  aorta  just  above  the  valves,  2  cm.  long  and  I  cm.  wide,  one 
end  advancing  into  the  anterior  aortic  cusp. 

Newton3  and  Cangee  combined  have  collected  44  cases  in  which  traumatisms  caused 
rupture  of  the  heart  without  opening  the  pericardium.  All  were  fatal  ;  one  lived  fourteen 
hours. 

The  fa^al  result  in  cases  of  rupture  of  the  heart  is  due  either  to  shock,  to  an  inability  of 
the  heart  to  contract  owing  to  its  injured  muscle,  or  to  pressure  on  the  heart  by  hemorrhage 
distending  the  pericardium  and  preventing  its  expansion. 

1  Brit.  Med.  Join.,  1894,  vol.  ii.,  p.  1427. 

2  Zeitschr.  f.  klin.  Med.,  Bd.  xlii.,  H.  5,  1 90 1. 

3  Medieal  Record,  June  17,  1899,  p.  864. 

893 


894  INTERNATIONAL    TEXT- BOOK  OF  SURGERY. 

Wounds  and  injuries  of  the  heart  and  pericardium  occur  in 
connection  with  injuries  to  the  thorax.  The  most  common  are  shot- 
and  stab-wounds,  while  perforations  and  tears  in  the  pericardium  by  the 
broken  end  of  a  rib  or  by  a  perforating  foreign  body  have  been  reported. 
The  possibility  of  a  wound  of  the  heart  or  pericardium  should  always 
be  considered  in  perforating  wounds  of  the  chest  in  the  cardiac  region. 

( )ne  of  the  greatest  dangers  is  that  the  coronary  artery  will  be  injured.  The  right  ven- 
tricle is  the  usual  site  of  injury. 

Rchn,1  of  Frankfort,  in  speaking  of  wounds  of  the  ventricle  as  compared  with  wounds 
of  the  auricle,  states  that  wounds  of  the  auricle  are  much  more  fatal  than  those  of  the  ven- 
tricle, owing  to  the  thinness  of  the  auricular  wall.  Giordano 2  reports  I  case  of  auricle 
suture  which  lived  nineteen  days. 

The  symptoms  of  wounds  of  the  heart,  when  death  is  not  immedi- 
ate, are  profound  shock,  severe  pain,  syncope,  hemorrhage,  either 
externally  or  into  the  pleural  or  pericardial  cavities,  diminution  of  the 
heart-sounds,  and  possible  enlargement  of  its  percussion  area. 

The  treatment  should  first  be  directed  to  the  relief  of  the  general 
symptoms.  The  foot  of  the  bed  should  be  raised,  the  patient  sur- 
rounded by  heaters,  stimulants  administered  only  in  sufficient  quanti- 
ties to  support  the  flagging  heart,  and  morphin  given  in  small  amounts 
repeated  frequently  enough  to  ease  the  pain.  The  question  of  opera- 
tion is  then  to  be  considered.  No  person  should  be  allowed  to  die 
from  a  wound  of  the  heart  without  an  operation  being  attempted,  when 
such  an  effort  would  give  the  slightest  possible  hope  of  a  favorable 
outcome.  Forty-one  per  cent,  of  all  reported  cases  operated  upon  have 
recovered ;   10  per  cent,  have  recovered  without  operation. 

Under  light  anesthesia3  a  flap  should  be  reflected  from  the  chest-wall 
over  the  wound,  and  a  sufficient  portion  of  one  or  more  ribs  resected 
to  give  access  to  the  wounded  heart.  The  pericardial  wound  should 
be  enlarged  if  necessary,  and  fine  silk  interrupted  sutures  used  to  close 
the  heart-wound.  The  sutures  should  be  passed  and  tied  during  dias- 
tole. Do  not  interrupt  the  rhythm.  The  pericardium  should  be  irri- 
gated with  hot  sterile  salt  solution. 

It  is  safer  not  to  suture  the  pericardium  completely,  but  to  insert 
through  the  external  wound  into  the  pericardial  cavity  a  small  wick  of 
gauze  for  drainage. 

There  have  been  several  cases  reported  of  recovery  following  attempts 
to  suture  or  to  control  hemorrhage  from  the  heart-wall. 

Rehn,4  of  Frankfort,  reports  a  case  of  knife-wound  of  the  left  chest  through  the  fourth 
intercostal  space,  in  which  a  portion  of  the  fifth  rib  was  excised,  the  pericardium  opened,  and 
a  wound  1 1/2  centimeters  (0.6  inch)  long  was  found  in  the  right  ventricle.  The  pericardium 
was  packed  with  iodoform  gauze.  The  patient  had  an  attack  of  purulent  pleuritis,  but 
finally  completely  recovered.  This  is  the  first  successful  case  of  suture  of  the  heart  in  man 
recorded. 

Spencer5  reports  a  case  of  a  man  twenty-eight  years  of  age  who  was  stabbed  through 
the  third  left  costal  cartilage.  The  wound  was  packed  with  gauze,  and  the  patient  lived 
seventy-nine  days.      At  the  autopsy  there  was  found  a  scar  5  mm.  (T3^  in.)  in  length  in  the 

1  Lancet,  1897,  vol.  i.,  p.  1306. 

2  La  chirurgia  del  pericardia  c  del  cuore,  Napoli,  1900. 

3  On  this  point  there  is  disagreement.  Parozzani,  by  Hill,  in  his  two  cases  used  no 
anesthetic.  Giordano  did  likewise,  but  has  no  objection  to  its  use  if  the  pulse  is  strong. 
In  Parlavecchio's  case,  struggling  from  the  anesthetic  caused  the  clot  to  be  detached  and 
the  bleeding  to  start  afresh.      Cocain  was  frequently  used  unless  the  patient  was  unconscious. 

*  Lancet,  1897,  vol.  i.,  p.  1306.  5  Brit.  Med.  Jour.,  1896,  vol.  ii.,  p.  1129. 


HEART  AXD   PERICARDIUM.  895 

right  ventricle,  and  a  smaller  scar  on  the  inside  of  the  heart,  just  below  the  pulmonary 
valve. 

Williams  l  reports  a  case  of  stab- wound  where  the  fifth  rib  was  temporarily  resected  ;  the 
wound  in  the  pericardium  was  found  to  be  1  %  inches  long  and  the  wound  of  the  heart  TL 
inch  long.  The  pericardium  was  irrigated  with  sterile  salt  solution,  and  the  wound  in  the 
pericardium  was  closed  with  fine  catgut  sutures.  The  external  wound  was  closed  with  sutures. 
The  patient  three  years  later  was  well. 

Hill 2  has  collected  all  the  cases  (17)  of  heart  suture  reported  up  to  1901.  There  were 
7  recoveries. 

Vaughn 3  reports  1  case  and  collects  8  more,  making  a  total  of  26  cases  with  9  recoveries. 

Occasionally  cases  are  reported  of  wounds  of  the  left  ventricle  where 
recovery  ensued  without  suturing.     For  example : 

Deane*  reports  a  stab- wound  of  the  left  ventricle.      Recover)-.      \o  suturing. 

Of  gunshot  wounds  of  the  heart  there  have  been  only  3  cases  reported  cured.  These 
were  operated  on  by  pericardial  drainage  only. 

One  of  the  most  interesting  cases  of  spontaneous  recovery  from  a  gunshot  wound  of  the 
heart  is  reported  by  C.  H.  Mastin,5  of  Mobile,  Ala.  A  man  aged  thirty-two  was  fired  at 
from  an  ambush,  and  his  left  chest  was  perforated  by  a  38-caliber  bullet.  It  entered  the  rear 
of  the  chest,  just  below  and  to  the  outer  side  of  the  angle  of  the  scapula,  at  which  point  it 
entered  the  chest  between  the  seventh  and  eighth  ribs.  It  passed  through  the  entire  chest 
and  emerged  from  the  fourth  intercostal  space,  2  v2  inches  from  the  midsternal  line.  Upon 
this  anatomical  location  it  is  not  possible  for  the  heart  to  have  escaped  direct  penetration. 
The  patient  fully  recovered. 

Foreign  bodies  may  penetrate  the  myocardium  and  there  remain, 
without  serious  results,  some  hours  or  up  to  many  years. 

Hill  (loc.  cit.\  reports  the  case  of  a  needle  2*4  inches  long,  driven  into  the  heart,  which 
could  be  seen  under  the  skin  moving  with  the  heart-beat.  It  was  removed  with  ease.  He 
quotes  a  case  of  Stevenson's  where  a  British  officer  carried  a  bullet  encapsulated  in  the  heart- 
wall  for  eleven  years.  He  quotes  Beers  also,  who  tells  of  an  American  soldier  who  bore  a 
bullet  in  the  wall  of  the  left  ventricle  for  thirty-seven  years. 

Ophulus6  has  collected  47  cases  of  foreign  body  in  the  heart- wall. 

One  of  the  most  suggestive  cases  as  to  the  wisdom  of  intervention  in  suspected  ruptures 
of  the  heart  is  that  of  Flamet,7  who  reports  the  case  of  a  soldier  who.  while  attempting  to 
lift  the  trunk  of  a  tree,  was  seized  with  a  sudden  severe  pain  in  the  right  chest.  It  was 
thought  that  he  had  ruptured  a  costal  cartilage  by  the  action  of  the  pectoralis  major  muscle. 
He  was  examined  at  the  hospital  the  next  day.  but  no  lesion  could  be  found,  and  the  heart 
and  respiration  were  normal.  He  walked  about  the  yard  and  felt  comfortable  during  the 
day.  The  following  morning  he  suddenly  complained  of  pain  and  expired  almost  at  once. 
At  the  autopsy  an  ordinary  sewing-needle  was  found  to  have  penetrated  the  chest-wall  in  the 
fourth  right  intercostal  space  and  was  buried  in  the  pericardium.  The  pericardial  cavity 
was  found  to  be  filled  with  blood,  and  this  it  is  which  is  significant  and  should  be  recog- 
nized as  a  demand  for  surgical  interference.  On  .the  surface  of  the  right  ventricle  were 
found  two  small  erosions,  one  of  which  disclosed  an  opening  into  the  cavity  of  the  heart. 

As  illustrating  a  method  of  exposure  of  the  heart  and  pericardium 
in  stab-wounds  of  the  cardiac  region,  Roberts's  article  on  the  subject 
of  Suppurative  Pericarditis,  which  was  read  before  the  American  Sur- 
gical Association  in  1897,  is  of  interest.  He  proposed  an  operation 
consisting  of  a  chondroplastic  method  of  pericardotomy,  by  a  trap-door 
excision  of  costal  cartilages,  which  avoided  injury  to  the  pleura  and 
mammary  vessels. 

An  extremely  suggestive  case  as  to  the  possibilities  of  cardiac  sur- 
gery is  the  one  reported  by  F.  C.  Shattuck  and  C.  B.  Porter8  of  cure  of 

1  Med.  Record,  1897,  vol.  li..  pp.  437-439. 

2  Medical  Record,  Dec.  15,  1900,  p.  921. 

3  Medical  News,  Dec.  7,  1901.  *  Pacific  Med.  Jour.,  1895,  vol.  xxxviii.,  p.  209. 

5  Trans.  Am.  Surg.  Assoc,  vol.  xiii.,  p.  273. 

6  Occid.  Medical  Times,  June,  1S99,  p.  426. 

7  Archives  de  Medecine  et  de  T/iar?/iacie  Militaires,  Paris,  Nov.,  1892. 

8  Mass.  Med.  Soc,  1900,  p.  369. 


896  INTERNATIONAL    TEXT-BOOK   OE  SURGERY. 

a  purulent  pericarditis.     The  steps  of  the  operation  recommended  by 
Porter  are : 

An  incision  is  to  be  made  from  the  middle  of  the  sternum  outward  over  the  fifth  costal 
cartilage  to  its  junction  with  the  rib.  The  soft  parts  are  cleaned  from  the  cartilage  with  a 
periosteum  elevator,  care  being  taken  not  to  wound  the  pleura.  The  cartilage  is  divided 
with  bone-forceps  from  the  rib  and  the  sternum.  The  internal  mammary  artery  and  vein 
are  thus  exposed,  ligated  in  two  places,  and  divided  between.  The  triangularis  sterni  is 
separated  from  the  sternum  and  pushed  to  the  left. 

A  little  careful  dissection  with  the  director,  in  case  fat  is  encountered,  exposes  the  peri- 
cardium, which  is  normally  much  thicker  than  the  pleura.  An  aspirating  needle  should 
now  be  introduced,  if  this  has  not  been  previously  done,  in  order  to  corroborate  the  diag- 
nosis. If  confirmed,  the  knife  should  follow  the  needle.  The  incision  in  the  pericardium 
is  best  made  obliquely  downward  and  outward,  beginning  close  to  the  excised  border  of  the 
sternum.     The  edges  of  the  pericardium  should  be  stitched  to  the  soft  parts. 

Irrigation  should  always  be  employed,  with  the  object  of  removing  any  masses  of  fibrin 
which  may  lie  at  the  bottom  of  the  cavity,  and  if  there  are  many  such  masses,  it  should  be 
continued  until  the  fluid  returns  clear.  The  fluid  may  be  weak  sublimate  or  carbolic  solu- 
tion or  salt  solution,  according  to  the  preference  of  the  operator.  The  fluid  must  be  warm 
and  have  free  exit. 

Drainage  is  best  provided  by  two  rubber  tubes,  one  long  and  reaching  to  the  bottom  of 
the  sac  for  the  inflow,  and  a  short  tube  just  entering  the  sac  for  the  outflow.  As  the  dis- 
charge diminishes  one  tube  may  be  removed,  and  finally  gauze- drainage  inserted. 

Eiselsbergi  of  Vienna  reports  a  case  where  a  purulent  pericarditis  developed  after  a 
stab-wound  of  the  pericardium  in  a  boy  seventeen  years  of  age.  Puncture  of  the  pericar- 
dium having  been  performed  several  times  without  relief,  an  incision  was  made,  the  cartilage 
of  the  fourth  left  rib  was  resected  and  the  thickened  pericardium  exposed.  This  was  opened 
by  a  transverse  incision  4  centimeters  (ii  inches)  in  length,  and  2  liters  (2.1  quarts)  of  a 
seropurulent  fluid  were  evacuated.  The  cavity  was  irrigated  out  with  warm  salicylated 
water,  the  borders  of  the  pericardial  incision  were  stitched  to  those  of  the  wound,  two  drain- 
age-tubes inserted,  and  complete  recovery  took  place  in  four  weeks. 

Dalton  2  of  St.  Louis  reports  a  case  of  a  man,  aged  twenty-two,  who  had  a  wound  oi 
the  pericardium.  He  was  seen  an  hour  after  the  injury,  and  his  immediate  symptoms  were 
very  slight.  Ten  hours  later  his  temperature  rose  to  loi°  F.,  pulse  to  112,  respirations  to 
40.  The  entire  left  side  had  become  dull.  An  incision  8  inches  long  was  made  over  and 
parallel  with  the  fourth  rib,  and  6  inches  of  the  rib  were  excised.  The  pleural  cavity 
was  found  filled  with  fluid  and  clotted  blood.  There  was  a  wound  in  the  pericardium  2 
inches  in  length,  which  was  sutured  with  much  difficulty,  owing  to  the  rapidity  of  the  heart's 
action  (140  a  minute).      His  recovery  was  rapid  and  uninterrupted. 

In  conclusion,  it  may  be  said  that  an  exploratory  operation  is  ad- 
visable in  any  case  where  a  wound  of  the  heart  or  pericardium  is  sus- 
pected, for  the  following  reasons  :  1.  To  secure  asepsis  ;  2.  To  prevent 
the  outpouring  of  blood  from  a  possible  wound  in  the  heart-muscle 
into  the  pericardium,  since  such  an  outflow,  apart  from  the  effects  of 
hemorrhage,  overdistends  the  pericardium  and  stops  the  heart's  action. 

INJURIES  OF  THE  BLOOD-VESSELS. 

The  surgery  of  the  blood-vessels  may  be  divided  into  two  classes : 
1.  Injuries;  2.  Diseases. 

As  the  result  of  injury  to  a  blood-vessel  there  occur  several  forms 
of  hemorrhage.     These  are  known  as  arterial,  venous,  and  capillary. 

Hemorrhage. — a.  Arterial ;  b.  Venous  ;  c.  Capillary. 

In  order  to  understand  hemorrhage  .intelligently  it  will  be  necessary 
to  recall  the  anatomy  of  the  vessels. 

All  of  the  arteries  have  distinct  coats ;  the  internal  or  endothelial  is 
known  as  the  tunica  iutiuia,  the  middle  muscular  coat  as  the  tunica 
media,  and  the  external  connective-tissue  coat  as  the  tunica  adventitia. 

1  Wiener  kliniscke  Wochenschrift,  Jan.,  1895. 

2  Annals  of  Surgery,  Feb.,  1895. 


INJURIES    OF   THE   BLOOD-VESSELS.  897 

The  two  inner  coats  are  intimately  connected,  but  together  may  be 
easily  separated  from  the  outer  one,  which  is  dense  and  firm. 

The  tunica  intima  is  a  serous  lining  continuous  throughout  the  vas- 
cular system.  It  has  no  vessels  and  is  composed  chiefly  of  an  epithelial 
lining  and  a  layer  of  longitudinal  elastic  fibers  and  connective  tissues. 

The  tunica  media  consists  of  two  layers — an  elastic  and  a  muscular 
coat — whose  fibers  are  arranged  in  a  circular  direction,  and  give  to  the 
artery  its  patency,  form,  and  elasticity.  The  elastic  fibers  predominate 
largely  in  the  aorta  and  its  large  branches,  while  the  muscular  fibers 
predominate  in  the  smaller  arteries. 

The  tunica  adventitia  is  a  tough  membranous  coat  composed  mainly 
of  connective  tissue.  It  gives  to  the  arteries  their  chief  strength  and 
firmness,  and  from  it  the  inner  coats  derive  their  nerve  and  part  of  the 
blood-supply. 

Arterial  Hemorrhage. — When  the  artery  is  divided,  an  intermittent 
stream  of  bright- red  blood  spurts  from  the  proximal  end  of  the  injured 
vessel.  However,  in  case  of  partial  asphyxia  from  ether  or  other  cause 
the  blood  is  of  a  dark-red  color  like  venous  blood.  The  spurting 
stream  which  is  usually  seen  is  synchronous  with  the  heart-beat,  but  if 
the  hemorrhage  comes  from  a  deep  wound  this  spurting  is  obscured. 
This  is  also  the  case  where  severe  hemorrhage  has  occurred  or  where 
there  is  great  cardiac  weakness  from  lowering  of  the  arterial  pressure. 
Bleeding  from  large  arteries  must  be  controlled  mechanically,  while 
bleeding  from  the  smaller  arteries  usually  ceases  on  account  of  the 
retraction  of  the  vessels  within  their  sheaths  and  the  spontaneous  clot- 
ting of  the  blood. 

Venous  Hemorrhage. — When  a  vein  is  divided  there  is  a  continuous 
flow  of  dark-red  blood,  and,  unlike  arterial  hemorrhage,  the  flow  is 
greater  from  the  distal  end  of  the  severed  vessel  than  from  the  proxi- 
mal end.  Venous  hemorrhage  is  not  often  dangerous,  unless  it  occurs 
from  a  large  vein  near  the  trunk  or  from  a  large  branch  near  a  main 
vein.  Fatal  hemorrhage  occasionally  occurs  from  a  ruptured  varicose 
vein  in  the  leg,  owing  to  the  valves  in  the  vein  becoming  inefficient 
from  dilatation  of  the  vessel.  In  a  hemorrhage  from  a  vein  the  simple 
expedient  of  elevating  the  limb  and  applying  slight  pressure  to  the 
bleeding  point  quickly  controls  the  hemorrhage.  A  serious  danger  in 
connection  with  venous  hemorrhage  from  large  trunks,  especially  in  the 
neck,  is  the  entrance  of  air  into  the  circulation,  forming  air-emboli. 

Capillary  hemorrhage  differs  from  arterial  and  venous  hemorrhage 
in  that  blood  flows  from  a  large  number  of  minute  points  in  the  tissues 
rather  than  from  a  single  vessel  of  considerable  size.  The  blood  seems 
to  well  up  from  the  wound  like  water  from  a  spring.  It  is  bright  red 
in  color,  and  unless  from  a  constitutional  dyscrasia  always  ceases  spon- 
taneously from  the  coagulating  property  of  the  blood. 

Control  of  Hemorrhage. —  The  blood  and  the  vessels  have  been 
provided  with  a  number  of  important  properties  for  the  control  of 
hemorrhage,  which  in  the  majority  of  cases  are  sufficient  to  prevent  a 
fatal  result.  These  are  coagulation  of  the  blood  and  the  formation  of 
thrombi ;  retraction  and  contraction  of  the  vessel-walls  ;  and  the  con- 
traction and  pressure  of  the  surrounding  tissues.  After  a  serious  loss 
of  blood  there  is  cardiac  weakness  and  a  consequent  falling  off  in  the 
57 


898  INTERNATIONAL    TEXT-BOOK  OF  SURGE RiT. 

blood-pressure,  which  lessens  the  loss  of  blood  and  favors  coagulation. 
The  underlying  principle  in  the  control  of  all  kinds  of  surgical  hemor- 
rhage is  the  proper  application  of  pressure.  Constitutional  treatment 
by  the  administration  of  ergot,  iron,  opium,  etc.,  to  lower  the  blood- 
pressure  and  favor  coagulation,  lowering  of  the  head  to  prevent  fatal 
syncope,  and  the  transfusion  of  a  normal  salt  solution,  are  all  valuable 
adjuvants. 

There  are  a  number  of  devices  for  controlling  hemorrhage  by  press- 
ure, many  of  which  are  always  available.  The  most  important  of  these 
are  digital  pressure,  improvised  tourniquets,  or  pressure  by  a  compress  pad 
and  bandage.  Other  measures  are  packing  a  wound  with  gauze,  the 
use  of  hemostatic  forceps  for  temporary  compression,  torsion,  and  liga- 
tion. In  addition  to  these,  position,  heat,  cold,  styptics,  and  the  actual 
cautery  are  frequently  of  great  value.  The  details  for  the  treatment  of 
hemorrhage  and  the  applications  of  the  various  remedial  measures  will 
be  found  in  the  chapter  on  Minor  Surgery. 

During  the  last  three  years  much  experimental  work  has  been  done  to  determine  the 
value  of  subcutaneous  injections  or  local  applications  of  gelatin  solutions  to  stop  hemor- 
rhage— internal  or  for  some  other  reason  uncontrollable  mechanically.  This  applies  to 
hemophilia  and  to  bleeding  from  the  nose,  nasopharynx,  and  intestines.  These  solutions 
have  particularly  been  used  for  injections  into  aneurysms  (</.  v.). 

Excellent  experimental  work  has  been  done  by  Mariani,1  who  concludes  that  subcu- 
taneous injections  of  2  per  cent,  solutions  of  gelatin  in  normal  saline  solutions  are 
absorbed;  that  they  are  innocuous;  that  they  increase  the  coagulability  of  the  blood  as  a 
pure  modification  of  its  density.  Grunow  'l  believes  that  gelatin  used  subcutaneously  has 
a  transient  "blood-coagulating  quality  which  is  useful  in  controlling  hemorrhage  of  the 
internal  organs.  Sailer3  has  collected  the  literature  of  the  subject  to  date.4  Repeated 
hypodermic  injections,  therefore,  of  a  sterile  I  or  2  per  cent,  solution  of  gelatin,  each  dose 
amounting  to  I  to  3  grams  pure  gelatin,  may  be  made  for  hemophilia  or  for  internal  bleed- 
ing not  otherwise  controllable. 

Rarely  in  these  days  of  antisepsis  does  a  secondary  hemorrhage 
take  place.  It  may,  however,  be  due  to  the  slipping  of  a  ligature,  to  an 
atheromatous  artery,  to  sloughing  in  a  wound  that  is  the  result  of  any 
septic  process,  or  to  gangrene.  Arterial  hemorrhage  may  be  primary 
— recurrent  within  twenty-four  hours — or  secondary,  from  any  time 
after  this  until  the  wound  in  the  vessel  is  healed. 

In  pre-antiseptic  days  secondary  hemorrhage  was  of  frequent  occur- 
rence, and  often  took  place  when  the  ligature  separated,  which  was  from 
the  twelfth  to  the  sixteenth  day.  The  treatment  of  secondary  hemor- 
rhage is  as  follows  :  In  case  the  bleeding  is  confined  to  a  small  amount 
of  oozing,  packing  the  wound  with  iodoform  gauze  and  the  application 
of  a  firm  bandage  with  compression  are  usually  sufficient  for  its  control. 
If,  however,  the  hemorrhage  becomes  profuse,  an  Esmarch  tourniquet 
must  be  applied,  or  digital  pressure  made  over  the  artery,  the  wound 
opened,  and  a  ligature  applied  to  the  ends  of  the  bleeding  vessel.  In  a 
sloughing  wound  or  in  a  nearly  healed  stump  it  is  often  advisable  to 
ligate  the  vessel  in  continuity. 

Air-embolism,  or  the  entrance  of  air  into  the  circulation,  aside 
from  where  it  enters  the  uterine  sinuses,  occurs  exclusively  after  injury 
to  the  veins,  especially  those  at  the  base  of  the  neck — i.  e.,  the  jugular, 

1  //  Policlinico,  1901,  No.  12. 

2  Berlin,  klin.   Wochens.,  Aug.  12,  1901. 
s  Therap.  Gaz.,  Aug.  15,  1901,  p.  5°8- 

4  See  also  Nichols,  Medical  News,  1899,  p.  705. 


INJURIES   OF   THE  BLOOD-VESSELS.  899 

the  superior  vena  cava,  the  innominate,  the  subclavian,  and  the  axillary. 
The  facts  that  these  are  large  veins  with  a  stream  of  blood  running 
downward  toward  the  heart,  that  they  usually  do  not  collapse  when 
wounded,  being  held  open  by  their  attachments  to  the  surrounding 
connective  tissue  and  fascia,  and  that  when  inspiration  occurs  the  blood- 
pressure  becomes  negative  in  these  veins,  all  favor  the  entrance  of  air 
when  they  are  wounded.  The  air  rushes  in  with  a  peculiar  hissing  or 
gurgling  sound,  and  if  in  sufficient  quantities  death  is  almost  instan- 
taneous. Single  small  bubbles  of  air  are  not  necessarily  fatal,  but  may 
cause  labored  breathing  and  tumultuous  cardiac  action.  Death  is  due 
to  the  air  collecting  in  the  right  side  of  the  heart  and  preventing  the 
contraction  of  the  right  ventricle,  which  finally  stops  the  heart  in  dias- 
tole. 

Treatment  of  Air=emboIism. — Unfortunately  the  accident  is  not 
usually  recognized  until  the  serious  condition  of  the  patient  warns  the 
surgeon  of  approaching  death.  It  more  commonly  occurs  in  a  surgical 
operation  than  in  the  case  of  an  accidental  or  a  self-inflicted  wound. 
When  a  large  vein  is  cut  it  should  be  instantly  compressed  on  the 
cardiac  side  by  the  finger,  and  the  wound  should  be  kept  filled  with 
sterilized  water  until  the  vessel  is  ligated.  As  soon  as  the  bleeding 
vein  is  secured,  the  patient's  general  condition  should  receive  attention. 
Inhalations  of  oxygen,  forcible  expiratory  movements  by  compression 
of  the  chest,  electricity  to  the  chest  over  the  heart,  bandaging  of  the 
limbs,  and  subcutaneous  injections  of  strychnin  or  atropin  should  all  be 
tried.  Operations  in  the  vicinity  of  the  veins  in  the  lower  part  of  the 
neck  should  be  conducted  with  the  greatest  care,  and  an  assistant 
should  stand  near  at  hand,  ready  to  apply  compression  in  case  of  need. 

Wounds  of  the  arteries  and  veins  occur  in  connection  with 
wounds  of  all  kinds  and  in  every  part  of  the  body,  and  give  rise  to  the 
different  varieties  of  hemorrhage  previously  enumerated.  The  first 
indication  in  these  wounds  is  to  control  the  hemorrhage  by  compres- 
sion, ligature,  or  packing. 

It  is  very  rare  that  in  an  operation  a  surgeon  will  be  called  upon  to 
suture  an  artery,  but  it  has  been  demonstrated  by  Gluck  l  and  also  by 
Heidenhain  that  the  axillary  artery,  if  it  is  not  completely  divided,  may 
be  restored  in  its  continuity.  Wounds  of  the  internal  carotid,  the 
brachial,  the  common  iliac,  the  femoral,  and  the  popliteal  have  also 
been  successfully  sutured.2  The  edges  of  the  artery  are  seized  by  for- 
ceps, fine  catgut  sutures  are  introduced  through  the  adventitia,  and  the 
wound  is  packed  down  to  the  sutured  vessel.  Heidenhain  examined 
his  case  of  suture  of  an  artery  six  months  later  and  found  no  evidence 
of  a  traumatic  aneurysm. 

Not  infrequently  in  operations  where  large  veins  are  involved  a  sur- 
geon will  find  a  bleeding  point  on  the  wall  of  a  vein  which  requires 
repair.  This  can  be  done  by  seizing  the  bleeding  point  and  applying  a 
ligature  to  pucker  up  the  wall  of  the  vein,  and,  as  has  been  done  in 
treating  arteriovenous  aneurysms,  the  wall  of  the  vein  might  be  sewed 
in  on  itself  by  fine  catgut  sutures  in  the  axis  of  the  vessel. 

Rupture  of  an  artery  occasionally  occurs  as  the  result  of  direct  or 

1  Centralbl.  fur  Ckirurgie.,  1895,  No.  49. 

2  Editorial,  Jour.  Amer.  Med.  Assoc,  April,  1900,  p.  10S7. 


900  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

indirect  violence.  The  rupture  may  be  complete  through  all  three 
coats,  or  it  may  be  only  partial  through  one  or  more  coats  of  the 
vessel.  The  walls  of  an  artery  may  be  torn  as  the  result  of  a  blow,  or 
the  wall  may  give  way  from  increased  blood-pressure  when  weakened 
by  atheroma.  If  an  artery  is  stretched  from  overextension,  especially 
at  the  knee-joint,  or  where  the  vessel  is  caught  against  the  bone  or 
between  the  fragments  of  a  fracture,  or  where  it  is  bruised  in  the 
reduction  of  dislocations  at  the  hip-  or  the  knee-joint,  a  rupture  may 
take  place.  Partial  rupture  of  an  artery  resulting  in  aneurysm  may 
come  on  without  apparent  violence,  as  a  sequel  to  endarteritis.  When 
rupture  occurs  in  a  large  artery  with  no  external  wound,  the  blood 
spreads  through  the  tissues,  forming  an  arterial  hematoma,  and  the 
bleeding  internally  is  controlled  only  by  the  pressure  of  the  surround- 
ing tissues.  A  large  ill-defined  swelling  forms,  giving  rise  to  great 
pain,  and,  if  it  continues,  the  limb  becomes  cold,  swollen,  numb,  and 
pulseless.  There  is  usually  no  pulsation  in  the  swelling.  The  diag- 
nosis in  these  cases  rests  frequently  between  a  ruptured  vessel  and  a 
deep  abscess  and  is  often  very  obscure,  and  aspiration  maybe  necessary 
in  case  of  doubt.  If  rupture  of  a  large  blood-vessel  takes  place  into 
one  of  the  large  cavities  of  the  body,  fatal  hemorrhage  is  almost  inevi- 
table. 

The  treatment  in  these  cases  varies  according  to  the  character  of 
the  injury,  the  magnitude  of  the  hemorrhage,  its  location,  and  the  age 
and  condition  of  the  vessels  of  the  patient.  If  the  injury  is  of  such  a 
character  that  it  is  believed  that  a  large  vessel  has  been  torn  across,  an 
incision  should  be  made,  the  blood  evacuated,  and  the  torn  vessel 
ligated.  This  is  equally  true  if  the  hemorrhage  into  the  surrounding  parts 
is  increasing.  If,  however,  the  patient's  vessels  are  seriously  diseased 
by  endarteritis  or  atheroma,  it  may  be  difficult  to  find  a  place  to  secure 
the  artery.  General  atheroma  is  a  contra-indication  to  any  operation 
in  these  cases.  Ordinarily  the  limb  should  be  carefully  supported  on 
a  pillow,  wrapped  in  sheet-wadding  and  kept  warm,  and  watched.  If 
the  swelling  increases  there  is  danger  of  gangrene,  and  an  operation 
may  be  advisable.  Rupture  of  diseased  arteries  from  aneurysm  results 
in  nothing  different  from  simple  traumatic  rupture  unless  it  occurs  into 
one  of  the  large  cavities  of  the  body,  in  which  case  there  is  usually  a 
fatal  hemorrhage. 

Atraumatic  aneurysm  differs  from  an  arterial  hematoma  in  the 
fact  that  all  the  coats  of  the  vessel  are  not  ruptured.  The  remaining 
uninjured  coats  being  insufficient  to  withstand  the  blood-pressure,  the 
vessel  gradually  stretches  and  gives  way  at  the  weakened  point,  and 
an  aneurysmal  sac  is  formed.  The  symptoms,  treatment,  and  progress 
of  a  traumatic  aneurysm  are  identical  with  those  of  an  ordinary  aneu- 
rysm. A  traumatic  aneurysm  may  be  distinguished  from  an  arterial 
hematoma  by  its  distinct  outlines,  by  its  pulsating  character,  and  by 
the  presence  of  the  normal  pulse  in  the  limb. 

Rupture  of  a  vein  often  occurs  as  the  result  of  traumatism  to  a 
varicose  vein.  When  the  rupture  is  subcutaneous  a  venous  hematoma 
forms,  often  of  considerable  size  and  just  beneath  the  skin.  Usually, 
however,  the  hemorrhage  ceases,  owing  to  the  low  blood-pressure  in 
the   veins,  before    the    amount  of  extravasation  becomes    dangerous. 


INJURIES   OF  THE  BLOOD-VESSELS.  901 

The  extravasated  blood  is  generally  absorbed.  Not  infrequently,  how- 
ever, owing  to  the  low  state  of  the  vitality  of  the  patient  and  the  ten- 
sion on  the  skin,  the  extravasation  is  followed  by  inflammation  and 
suppuration.  Where  this  occurs  there  is  increased  pain,  with  redness 
and  swelling.  In  such  cases,  where  it  is  clearly  determined  that  inflam- 
mation has  taken  place,  an  early  incision  should  be  made,  the  blood- 
clot  turned  out,  and  the  wound  packed  with  iodoform  gauze.  Open 
ruptures  of  the  vein  should  be  controlled  by  elevating  the  limb  and 
applying  pad-pressure  to  the  point  of  rupture,  under  antiseptic  pre- 
cautions. 

Repair  of  Arteries  and  Veins. — When    an    artery  is    divided  sub- 
cutaneously  there  is  always  a  considerable  hemorrhage,  with  a  collec- 


\ 


FIG.  441. — Femoral  artery  of  man  three  months  after  ligature;  proximal  end,  termination 
of  healing  process.  The  cicatrix,  composed  partly  of  muscular  cells,  is  penetrated  by  a  small 
vessel.     Below  is  the  fibrous  tissue  which  unites  the  proximal  to  the  distal  end  (Warren). 

tion  of  blood-clot  outside  and  inside  the  ruptured  vessel.  If  there  is 
no  open  wound,  the  clot  gradually  becomes  absorbed  and  granulation- 
tissue  takes  its  place.  Where  the  divided  vessel  is  large  and  the 
wound  involves  only  a  part  of  its  wall,  the  granulation-tissue  eventually 
becomes  connective  tissue  and  forms  a  cicatrix.  This  cicatrix  is  seldom 
sufficiently  firm  to  withstand  the  blood-pressure,  and  an  aneurysm  is 
likely  to  form  at  the  injured  point.  When  the  artery  is  completely 
ruptured  or  when  the  vessel  is  firmly  ligated,  the  blood  in  the  injured 
ends  coagulates,  forming  what  is  known  as  a  thrombus  (see  Fig.  38, 
page  138).     This  thrombus  extends  from  the  point  of  interruption  in 


902  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

the  vessel  in  both  directions — proximally  to  the  nearest  branch  given 
off,  and  distally  but  a  short  distance.  This  thrombus-formation  takes 
place  in  any  vessel  whenever  the  normal  integrity  of  its  epithelial  lin- 
ing is  in  any  way  impaired.  After  the  thrombus  is  formed,  it  undergoes 
a  change  which  consists  of  the  gradual  supplanting  of  the  thrombus 
by  cellular  infiltration,  by  the  formation  of  granulation-tissue  and  of 
blood-vessels  which  penetrate  the  thrombus  in  all  directions.  This 
finally  becomes  connective  tissue  and  completely  replaces  the  throm- 
bus. In  this  way  is  formed  the  cicatrix  which  successfully  closes  the 
vessel  (Fig.  441).  The  replacement  of  the  thrombus  by  connective 
tissue  is  largely  accomplished  by  a  proliferation  of  the  endothelial  cells 
of  the  intima,  and  the  time  required  for  the  completion  of  the  process 
in  the  vessel  varies  greatly  with  the  size  of  the  vessel  and  with  the 
power  of  repair  possessed  by  the  individual.  The  same  process  of 
repair  occurs  in  the  veins  as  in  the  arteries,  but  in  the  veins  thrombi 
form  more  easily  and  are  more  extensive  than  in  arteries. 

DISEASES  AND  INFLAMMATORY  CHANGES  OF  THE  BLOOD-VESSELS. 

Arteritis  is  a  distinct  form  of  inflammation  which  involves  all 
three  coats  of  the  wall  of  an  artery. 

Acute  arteritis  may  occur  as  a  primary  affection,  as  the  result  of 
an  injury  or  of  direct  bacterial  infection;  it  maybe  secondary  to  a 
septic  thrombosis  or  embolism  forming  or  lodging  in  an  artery,  or 
to  the  existence  of  inflammatory  disease    in  the  surrounding  tissues. 

Acute  arteritis  in  the  course  of  influenza  and  after  other  acute  infective  diseases, 
notably  typhoid  fever,  is  not  infrequent.  It  involves  especially  the  arteries  of  one  or 
both  legs. 

Traumatic  Arteritis. — This  is  the  most  simple  form  of  inflamma- 
tion, and  arises  from  the  ligation  of  a  vessel,  or  after  wounds  or  bruises, 
or  following  the  lodgement  of  non-infective  emboli.  The  small  con- 
tiguous vessels  dilate,  lymph  is  poured  out  into  the  adjacent  tissues, 
and  granulation-  and  connective  tissue  form,  resulting  in  a  cicatrix  in 
the  wall  of  the  vessel. 

Suppurative  arteritis  commonly  begins  in  the  intima  from  the 
presence  of  an  infected  embolus,  or  it  may  occur  as  a  peri-arteritis,  in 
which  case  organisms  must  be  brought  to  the  vessel  by  lymphatics  or 
must  have  entered  through  a  wound.  Septic  emboli  lodging  in  a 
vessel  produce  a  very  acute  arteritis,  with  rapid  ulceration  and  destruc- 
tion of  the  vessel-wall.  This  occurs  during  the  course  of  an  ulcerative 
endocarditis.  When  the  suppurative  arteritis  begins  in  the  adventitia 
the  course  of  the  process  is  much  slower,  and  the  vessel  often  gradu- 
ally ulcerates  through  or  becomes  weakened  and  gives  way.  This  is 
probably  partly  due  to  the  fact  that  the  outer  coat  of  the  artery  is 
more  resistant  than  many  tissues,  and  partly  because  septic  emboli 
contain  more  virulent  organisms.  Hemorrhage  of  an  alarming  nature 
rarely  takes  place  as  an  immediate  result  of  this  process,  but  death 
results  from  the  constitutional  infection  which  gives  rise  to  the  septic 
emboli. 

There  are  many  constitutional  diseases  and  conditions — for  example, 
rheumatism,  gout,  syphilis,  and  alcoholism — which  favor  the  formation 


DISEASES   OF  THE  BLOOD-VESSELS.  903 

of  chronic  arteritis.  The  results  of  chronic  arteritis  in  the  vessels 
themselves  are  fatty  degeneration,  calcification,  gummata  (occasionally- 
resulting  in  ulceration),  suppuration,  occlusion,  dilatation,  aneurysm, 
and  rupture  of  the  vessel-wall. 

Atheroma. — The  most  frequent  result  of  arteritis  is  atheroma ;  it 
is  a  very  common  condition  in  late  adult  life,  but  rarely  gives  rise  to 
symptoms.  It  often  exists  for  a  long  time  before  it  becomes  evident, 
and  probably  begins  between  thirty  and  forty  years  of  age,  especially 
in  those  addicted  to  the  abuse  of  alcohol.  The  places  in  which  we 
find  atheroma  are  those  portions  of  the  large  vessels  which  are  sub- 
jected to  the  greatest  strain  ;  as,  for  example,  the  arch  of  the  aorta, 
the  convex  portions  of  the  curve  in  vessels,  the  points  of  division  of 
arteries,  and  at  the  origin  of  branches.  Atheromatous  arteries  occur 
more  commonly  in  plethoric  persons  of  a  gouty  or  rheumatic  diathesis, 
in  those  with  renal  or  cardiac  disease,  and  in  alcoholic  and  venereal 
patients.  The  disease  may  occupy  successive  segments  of  the  vessel 
or  it  may  occur  in  large  or  small  patches,  variously  scattered  about. 
It  is  first  seen  in  the  intima  of  the  vessel  as  yellowish-gray  shining 
spots,  slightly  raised  above  the  surface.  The  spots  increase  in  size, 
often  coalesce,  and  then  become  more  yellow  and  distinctly  elevated. 
This  yellow  exudate,  which  occurs  beneath  the  intima,  is  gradually 
replaced  by  a  deposit  of  lime  salts.  Then  the  muscle-fibers  begin  to 
waste,  and  the  vessel  loses  its  elasticity  and  becomes  rigid.  Athero- 
matous arteries  are  stiff  and  inelastic,  and  the  parts  they  supply  are 
cold,  congested,  and  badly  nourished.  If  the  salts  are  deposited  in 
successive  rings  round  the  artery,  it  is  known  as  annular  calcifica- 
tion ;  if  in  patches,  it  is  called  laminar  calcification.  The  vessels  most 
commonly  attacked  by  atheroma  are  the  aorta,  the  iliac,  femoral,  cor- 
onary, and  radial  arteries.  The  presence  of  atheromatous  blood-vessels 
should  not  be  overlooked  in  deciding  as  to  the  advisability  of  an  oper- 
ation, for  it  is  well  known  that  the  loss  of  elasticity  in  the  blood-vessel 
may  produce  thrombosis,  embolism,  aneurysm,  or  apoplexy. 

Arteritis  deformans  is  the  name  given  to  a  condition  which  is  the 
result  of  atheroma,  in  which  extensive  dilatation  and  pouching  of  the 
walls  occur.  In  the  dilated  portions  the  media  has  undergone  exten- 
sive fatty  degeneration,  while  the  calcareous  matter  is  found  to  be  most 
abundant  in  those  parts  of  the  vessel-wall  which  are  the  least  dilated. 

Endarteritis  obliterans  is  one  of  the  evil  results  of  chronic  arteritis, 
and  consists  of  the  permanent  occlusion  of  the  lumen  of  the  vessel. 
The  process  begins  with  a  cellular  infiltration  of  the  intima,  which  sub- 
sequently becomes  changed  into  connective  tissue.  The  media  may 
also  become  involved  (Fig.  442).  Infiltrations  of  the  walls  of  the  vessel 
occur  in  syphilitic  and  tubercular  inflammation.  Gangrene  of  the 
part  may  occur  from  endarteritis  obliterans. 

Syphilitic  arteritis  is  a  special  form  of  the  disease,  especially  dan- 
gerous in  that  its  most  serious  lesions  are  found  in  the  vessels  of  the 
brain.  The  arteries  of  small  caliber  and  the  aorta  are  most  frequently 
involved.  The  process  consists  of  cell-infiltration  into  the  intima,  and 
the  lumen  of  the  vessel  may  be  partially  or  completely  occluded, 
resulting  in  endarteritis  obliterans. 

Rheumatic  arteritis  occurs  associated  with   acute  rheumatism,  and 


904  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

while  not  as  common  as   rheumatic  endocarditis,  yet  it  occasionally 
occurs  in  the  aorta. 

Symptoms  of  Arteritis. — Arteritis  may  be  recognized  by  pain  and 
tenderness  along  the  line  of  the  blood-vessels.  The  onset  is  sudden, 
the  pain  severe,  and  there  may  be  paresthesia  and  mottling  of  the  skin. 
The  vessel,  if  superficial,  may  be  felt  as  a  cord,  and  is  frequently  almost 
pulseless.  The  pulsation  may  be  modified  so  that  it  is  shortened  and 
jerky,  according  to  the  amount  of  obstruction.  When  the  vessel 
becomes  occluded  there  is  often  great  pain  with  a  feeling  of  great  ten- 
sion, a  loss  of  power  in  the  part ;  and,  while  gangrene  may  result  if 
the  vessel  is  an  important  one,  yet  collateral  circulation  may  be  estab- 
lished.    Eighteen  cases  have  been  collected  by  Ford.1 


Fig.  442. — Tibial  artery  from  a  case  of  senile  gangrene  of  the  foot  (obliterative  endarteritis) 

(Warren). 

Treatment. — The  acute  forms  of  arteritis  are  treated  by  the  admin- 
istration of  opium,  with  rest,  elevation  of  the  limb,  and  cold  applications 
to  the  part.  If  there  is  an  active  inflammation  around  the  artery — a 
peri-arteritis — poultices  may  be  applied,  and  under  certain  circumstances 
an  early  operation  for  the  evacuation  of  septic  or  purulent  material 
may  be  called  for.  In  chronic  arteritis  the  existence  of  any  predispos- 
ing disease,  such  as  rheumatism,  gout,  syphilis,  or  nephritis,  should  be 
recognized  in  order  to  receive  appropriate  treatment.  The  local  treat- 
ment should  consist  of  rest,  elevation  of  the  part,  and  careful  bandaging 
applied  to  the  limb  in  such  a  manner  as  will  assist  the  circulation.  The 
skin  and  kidneys  should  be  kept  active  by  daily  warm  baths  and  diu- 
retics. The  diet  should  be  plain  and  moderate  in  quantity,  and  the 
bowels  kept  free.  In  all  cases  of  this  description  there  is  danger  of 
aneurysm-formation  and  apoplexy,  and  the  tension  in  the  arteries  must 
be  reduced  to  a  minimum  by  the  avoidance  of  all  excitement  or  violent 
exercise.  In  senile  cases  the  danger  of  gangrene  should  be  avoided  as 
far  as  possible  by  keeping  the  extremities  warm  and  protecting  them 
from  injury. 

1  These  de  Palis,  1901. 


DISEASES   OF  THE   BLOOD-VESSELS.  9O5 

Anatomy  of  the  Veins. — The  veins,  like  the  arteries,  have  three 
distinct  coats :  The  intima  corresponds  to  and  is  a  continuation  of  the 
lining  of  the  arteries  ;  the  media  is  made  up  of  longitudinal  and  elastic 
fibers;  and  the  adveiititia  consists  largely  of  areolar  tissue.  The  thin- 
ness of  the  walls  of  the  veins  as  compared  with  those  of  the  arteries  is 
the  main  difference  between  them,  and  this  is  especially  so  in  the  mus- 
cular coat.  For  this  reason  the  veins  lack  firmness  and  contractility, 
and  the  absence  of  elasticity  is  the  reason  they  do  not  gape  open  when 
divided.  The  thinness  of  the  walls  of  the  veins  renders  them  pecul- 
iarly liable  to  distention  and  stretching,  and  to  compensate  for  this 
lack  of  elasticity  and  to  assist  in  supporting  the  column  of  blood  they 
are  provided  with  valves,  which  are  especially  useful  in  the  lower 
extremities. 

Phlebitis. — An  inflammation  of  all  the  structures  which  go  to 
make  up  the  wall  of  a  vein  is  termed  phlebitis.  Clinically,  however, 
phlebitis  and  peri-phlebitis  are  the  only  forms  of  the  disease  which 
can  be  recognized,  and  even  that  distinction  is  not  always  possible. 
Phlebitis  may  be  acute,  subacute,  or  chronic,  and  it  occurs  more  fre- 
quently than  arteritis.  It  is  usually  confined  to  a  single  vein  in  contra- 
distinction to  inflammation  of  the  arteries,  where  usually  a  large  number 
of  vessels  are  involved.  The  vein  may  be  inflamed  throughout  its  whole 
length  or  only  for  a  short  distance.  Acute  phlebitis  may  be  simple, 
plastic,  or  purulent.  Simple  acute  phlebitis  may  be  due  to  a  number 
of  constitutional  diseases,  such  as  rheumatism,  gout,  or  syphilis,  or  it 
may  occur  irTsome  infectious  process,  as,  for  example,  typhoid  fever  or 
the  puerperal  state.  It  may  also  be  due  to  traumatism,  asin  ligation ; 
it  often  arises  from__a  thrombus,  an___Ujubcufus,  or  the-extension  of  an 
external  inflammatory  process. 

Suppurative  phlebitis  usually  occurs  in  the  perivascular  tissue,  and 
is  due  to  a^sjmple  phlebitis  having  become  infected.  It  is  seen  in  the 
sinuses  of  the  mastoid,  and  occasionally  occurs  in  cellulitis  and  in 
phlegmonous  erysipelas. 

Subacute  and  chronic  phlebitis  are  often_ass.ociatejd.with  varicose 
veins,  or  they  may  occur  in  the  course  of  some  constitutional  dyscrasia, 
such  as  syphilis.     This  form  of  the  disease  usually  attacks  the  outer 
coat  of  the  vein,  and  is  termed  a  periphlebitis^    There  is  thickening  of 
the  walls  of  the  vessel  from  the  deposit  of  fibrinous   material.     It  is 
naturally  much  less  dangerous  than  an  acute  phlebitis.    In  phlebitis  the 
coats  become  edematous  and  infiltrated  with  a  serous  exudate  and  with 
cells,  and  the  walls  become  thickened  and   more  vascular.     When  an 
inflammatory  process  begins  to  attack  the  intima  and  affects  the  endo- 
thelial lining,  the  formation  of  a  thrombus  begins.     On  the  other  hand, 
the  thrombus  may  be  primary  and  give  rise  to  the  foregoing  process. 
The  effect  is  the  same  in  either  case.     If  the  inflammation  subsides 
without  suppuration,  the  exudate  becomes  partially  absorbed  and  par- 
tially converted  into  fibrous  tissue,  but  leaves  a  permanent  thickening 
of  the  vessel-wall.     The  thrombus,  which  may  or  may  not  completely 
°«___l______,t^e  vessel,  may  be  absorbed  or  organized.     Subsequently  the 

le  vein  tends  to  regain  its  normal  size  and  appearance  as 

pies  absorbed  or  organized.     Primary  thrombi  are  apt  to 

le  veins,  in   the  vicinity  of  the  valves,  on  account  of  the 


go6  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

sluggish  current  at  these  points,  and  naturally  at  this  point  the  lodge- 
ment of  micro-organisms  may  take  place.  In  suppurative  phlebitis,  if 
the  lumen  of  the  vein  is  completely  occluded,  disintegrated  products  of 
the  inflammation  are  prevented  from  being  swept  into  the  circulation. 
If,  on  the  other  hand,  the  vein  is  not  occluded  or  the  thrombus  itself 
undergoes  degeneration,  suppurating  masses  containing  micro-organ- 
isms are  carried  by  the  circulation  to  various  parts  of  the  body  and 
result  in  metastatic  abscesses. 

Symptoms. — The  symptoms  of  phlebitis  differ  more  or  less  with 
the  cause  of  the  disease.  In  the  acute  form  the  constitutional  disturb- 
ance is  marked.  There  are  apt  to  be  chills,  high  temperature,  rapid 
pulse,  severe  pain,  a  dry,  coated  tongue,  restlessness,  and  delirium. 
There  are  usually  severe  pain  and  tenderness  along  the  course  of  the 
affected  vein.  The  more  superficial  veins  may  be  felt  as  small,  hard, 
knotted  cords.  The  veins  are  distended,  giving  rise  to  mottling  of 
the  skin.  If  thrombi  exist  in  the  veins,  especially  in  the  deep  ones, 
there  is  usually  sufficient  disturbance  in  the  circulation  to  produce 
edema  of  the  involved  part.  When  the  femoral  or  iliac  veins  are 
involved  the  disease  is  known  as  phlegmasia  alba  dolens  ("  milk-leg  "). 
In  the  suppurative  forms  of  the  disease,  if  the  infection  is  general,  there 
are  usually  associated  symptoms  of  septicemia.  In  the  subacute  and 
chronic  forms  of  phlebitis  the  pain  and  tenderness  are  less  marked  and 
more  circumscribed.  Pulse  and  temperature  are  lower,  delirium  and 
chills  are  absent.  The  chronic  form  of  the  disease  often  accompanies 
varicose  veins  of  the  leg,  which  usually  remain  quiet  if  properly  sup- 
ported ;  but  owing  to  the  defective  circulation  in  the  limb,  a  subacute 
process  is  easily  lighted  up  by  a  strain,  a  blow,  or  any  unusual  amount 
of  exercise.  Phlebitis  may  be  mistaken  for  lymphangitis,  neuritis,  neu- 
ralgia, or  rheumatism.  In  lymphangitis  the  skin  is  a  brighter  color, 
and  there  are  often  narrow  reddened  streaks  running  up  the  limb  as 
the  result  of  the  infection.  In  neuritis  and  neuralgia  the  pain  is  apt  to 
occur  in  paroxysms,  but  is  not  associated  with  superficial  redness  nor 
with  heat.  There  is  also  less  tenderness  in  neuritis  and  neuralgia  than 
in  phlebitis.  Rheumatism,  however,  may  often  be  differentiated  only 
by  treatment.  In  phlebitis  the  pain  is  usually  increased  by  motion, 
and  when  the  limb  is  allowed  to  hang  down,  the  pain  and  throbbing 
are  greatly  increased.  Gouty,  rheumatic,  or  syphilitic  phlebitis  can  be 
distinguished  only  by  the  history  of  the  case. 

Treatment  of  phlebitis  consists  in  putting  the  patient  to  bed  and 
giving  absolute  rest  to  the  involved  part.  This  is  imperative  in  order 
that  the  danger  from  thrombosis  may  be  minimized.  If  the  thrombus 
should  separate  and  cause  an  embolus,  it  may  end  in  immediate  death. 
The  limb  should  be  elevated,  as  this  position  favors  the  venous  circu- 
lation, relieves  the  tension  in  the  part,  and  prevents  pain  and  throbbing. 
A  large  flaxseed-meal  poultice  should  envelop  the  whole  limb,  and 
should  be  changed  every  two  hours,  if  necessaiy.  It  gives  the  most 
satisfactory  relief  to  the  pain  of  an  acute  inflammation.  Hot  fomen- 
tations, evaporating  lotions,  lead-and-opium  wash,  opium  and  bella- 
donna, and  solutions  of  nitrate  of  silver  are  all  recommended  for  ^exter- 
nal application,  and  are  useful  in  the  management  of  chronic  cases.  In 
acute  cases  the  patient's  physical  condition  may  be  seriously  involved. 


DISEASES   OF  THE   BLOOD-VESSELS.  907 

In  order  to  sustain  the  system  forced  feeding,  if  necessary,  together 
with  the  administration  of  stimulants,  should  be  used.  Quinin,  iron, 
and  saline  cathartics  are  all  indicated.  Naturally,  if  the  condition  is 
due  to  syphilis,  specific  treatment  should  be  tried,  and  it  is  often  neces- 
sary to  administer  potassium  iodid  freely  and  for  a  long  time  before 
any  improvement  occurs.  The  same  is  true  of  the  gouty  or  rheumatic 
type  of  the  disease,  for  which  appropriate  treatment  must  also  be  given. 
The  type  of  the  disease  that  occurs  in  stout,  plethoric  men  who  are 
hearty  livers  is  peculiarly  difficult  to  control.  They  should  be 
restricted  to  a  light  diet,  all  stimulants  prohibited,  and  the  emunc- 
tories  kept  free.  Massage  should  be  entirely  avoided,  as  there  is 
danger  of  an  embolus  separating  from  a  thrombus.  Even  when  skil- 
fully employed,  it  has  been  known  to  stir  up  a  chronic  phlebitis  to  an 
acute  form.  The  patient  should  be  kept  in  bed  for  many  weeks  after 
all  pain  and  tenderness  have  disappeared.  At  first,  gentle  passive 
motions  are  to  be  allowed,  and  then  the  patient  may  be  up  on  crutches 
At  this  time  the  limbs  should  be  carefully  bandaged  with  a  flannel 
bandage,  with  moderately  firm  pressure.  In  the  convalescent  stage 
electricity  may  be  used  in  restoring  the  strength  to  the  atrophied 
muscles,  and  its  use  may  be  combined  with  controlled  massage.  In 
case  of  suppurative  phlebitis  with  marked  localized  swelling  and  red- 
ness, where  there  is  thought  to  be  danger  of  abscess-formation,  early 
incisions  under  antiseptic  precautions  are  very  important.  By  this 
means,  if  the  thrombus  which  exists  in  the  vein  is  not  already  invaded, 
or  even  if  it  is  involved,  septic  emboli  and  pyemia  may  be  prevented. 
Brilliant  results  are  obtained  in  suppurative  otitis  media,  with  throm- 
bosis of  the  lateral  sinus,  by  early  trephining  of  the  mastoid.  Occa- 
sionally cases  of  suppurative  phlebitis  have  been  successfully  treated 
by  excising  the  involved  vein,  and  there  can  be  but  little  doubt  that  it 
is  a  justifiable  operation  to  ligate  the  cardiac  end  of  a  vein  filled  with  a 
septic  thrombus. 

Thrombosis  is  the  process  of  coagulation  of  the  blood,  during  life, 
in  the  interior  of  the  heart  or  a  blood-vessel.  The  clot  which  forms  is 
a  thrombus,  and  is  due  to  some  interruption  in  the  blood-current  at  a 
definite  point.  This  is  frequently  due  to  a  thickening  of  the  endothe- 
lial lining  of  the  vessel  at  the  point  where  the  thrombus  is  formed. 
A  ligature,  phlebitis,  or  varicose  veins  are  the  most  common  causes 
of  thrombi.  Acute  rheumatism,  syphilis,  continued  infectious  fevers, 
or  surgical  shock  where  the  heart  is  extremely  weak,  all  favor  the 
formation  of  thrombi.  The  local  injury  which  occurs  in  the  endothe- 
lial lining  of  the  vessel  may  be  due  to  a  simple  blow  or  pressure,  to 
the  presence  of  foreign  bodies,  or  to  any  of  the  inflammatory  diseases. 
Thrombi  which  are  found  during  life  are  distinguished  from  clots 
which  form  in  the  vessel  after  death  by  their  greater  consistency  and 
greater  adherence  to  the  vessel-wall.  The  adherence  of  the  thrombus 
may  be  due  to  simple  fibrin,  or  there  may  be  definite  tissue-formation 
between  the  thrombus  and  the  vessel-wall.  Thrombi  may  or  may  not 
occupy  the  whole  lumen  of  the  vessel.  They  are  usually  whitish  in 
color,  are  cone-shaped,  and  project  like  a  polypus  in  the  direction  of 
the  blood-current.  Thrombi  are  designated  as  venous  and  arterial, 
accordine  to   their   location.     Arterial   is   less   common    than    venous 


go8  INTERNATIONAL    TEXT-HOOK  OF  SURGERY. 

thrombosis.  Thrombi  are  also  designated  as  red,  white,  and  mixed 
thrombi,  according  to  their  color  and  composition,  ana  as  infective 
or  non-infective,  according  to  their  pathogenic  character.  The  infec- 
tive and  non-infective  thrombi  form  in  precisely  the  same  way,  but  the 
infective  thrombi  contain  bacteria  which  produce  a  purulent  softening 
of  the  thrombus,  so  that  it  becomes  a  soft,  friable  mass,  which  may 
break  up  and  enter  the  circulation  in  the  form  of  septic  emboli.  A 
non-infective  thrombus  undergoes  several  changes  after  its  formation, 
and  in  the  course  of  time  it  becomes  firm  and  hard.  In  its  interior, 
especially  in  the  larger  thrombi,  there  may  occur  a  non-septic  softening 
caused  by  the  breaking  down  of  the  cells.  Occasionally  a  thrombus 
may  undergo  a  complete  absorption  and  entirely  disappear,  or  it  may 
become  organized  into  connective  tissue.  This  is  known  as  organiza- 
tion of  the  thrombus,  and  it  is  due  to  gradual  cellular  infiltration  and 
the  growth  of  connective  tissue  from  the  wall  of  the  vessel.  A  throm- 
bus may  become  calcified  by  the  deposition  of  lime  salts,  and  it  is  then 
known  as  a  phlebolith,  ' 

The  symptoms  of  thrombosis  may  be  relatively  slight  until  the 
thrombus  reaches  sufficient  size  to  interfere  with  the  blood-current. 
Then  there  suddenly  occurs  severe  pain  in  the  part,  which  is  greatly 
increased  upon  motion  or  when  the  part  is  in  a  dependent  position. 
Acute  tenderness  or  induration_occurs  along  the  vessel ;  edema  of  the 
extremities  with  locaT~reoTness  and  swelling  is  a  part  of  the_process. 
Thereis  found  considerable  constitutional  disturbance,  with  high  tem- 
perature and  a  rapid  pulse.  Thrombi  more  frequently  occur  in  the 
vessels  of  the  extremities. 

The  treatment  of  thrombosis  is  of  necessity  expectant.  Absolute 
quiet,  in  order  to  promote  absorption  of  the  clot  and  to  prevent  detach- 
ment of  the  thrombus,  is  imperative.  Rest  should  be  insisted  upon 
until  all  acute  symptoms  have  subsided,  when  the  thrombus  will  either 
have  been  absorbed  or  have  become  attached  to  the  vessel-wall,  and 
the  danger  of  embolism  will  have  been  reduced  to  a  minimum.  The 
limb  should  be  elevated  to  relieve  congestion  and  to  favor  the  return 
of  circulation.  Large  flaxseed  poultices  should  be  kept  applied  to  the 
limb,  or  the  limb  may  be  carefully  bandaged  outside  of  a  thick  layer  of 
cotton  wadding.  The  employment  of  massage,  blisters,  iodin,  and  all 
counterirritant  measures  is  to  be  carefully  avoided  in  the  acute  stages 
of  the  process. 

.Embolism. — An  embolus  may  be  derived  from  a  number  of  differ- 
ent sources — for  example,  from  a  disorganized  thrombus,  from  calca- 
reous and  caseous  deposition  in  the  cardiac  valves,  from  malignant 
growths,  all  of  which  may  become  detached  and  swept  into  the  circu- 
lation. Occasionally,  fat  or  air  may  accidentally  be  introduced  into  the 
circulation  and  act  as  an  embolus.  The  place  where  the  embolus  lodges 
depends  upon  its  size  and  its  point  of  origin  :  those  which  come  from 
the  left  side  of  the  heart  lodge  in  the  arterial  system,  while  those  which 
separate  from  a  thrombosis  of  a  vein  are  carried  to  the  pulmonary 
arteries.  They  are  lodged  at  a  point  where  the  size  of  the  blood-vessel 
does  not  permit  them  to  advance  further — generally  where  the  large 
bcanrhe.sL_are  given  off  ns  there  .the  vessels  are  apt  to  be  diminished  in 
size  considerably.     If  the  embolism  obstructs  and  occludes  one  of  the 


DISEASES   OF   THE  BLOOD-VESSELS.  909 

large  branches  of  the  pulmonary  artery  or  the  middle  cerebral  artery, 
instant  death  usually  takes  place.  Emboli  may  undergo  the  same 
changes  as  thrombi — that  is  to  sav.  they  may  be  absorbed,  organized. 
or  softened-  An  occluding  embolus  in  a  healthy  and  well-nourished 
individual  may  occasion  only  temporary  and  local  disturbance,  as  the 
collateral  circulation  may  furnish  a  sufficient  blood-supply  to  the  part. 
Sudden  occlusion  of  a  large  and  important  vessel,  such  as  the  femoral 
artery,  will  produce  intense  congestion,  edema,  gang^rt^,  nn^  fmqnnntly 
deaths  If  the  embolus  is  an  infected  one,  the  organisms  which  it  con- 
tains set  up  a  purulent  necrotic  process  in  the  wall  of  the  vessel,  and 
this  is  known  as  a  secondary  abscess. 

The  symptoms  of  embolism  are  sudden  in  onset,  and  there  are  sharp 
pain  and  tenderness  along  the  course  of  the  vessel  and  the  parts  sup- 
plied by  it.  There  are  coldness,  numbness,  and  pallor  in  the  parts. 
The  symptoms  of  embolism  are  similar  to  those  of  thrombosis,  except 
that  they  are  more  sudden  and  pronounced  and  much  more  serious. 

The  treatment  of  embolism,  if  the  part  involved  is  a  limb,  consists 
in  rest,  elevation  of  the  limb,  and  the  application  of  warmth  to  the  part 
to  favor  the  return  of  the  circulation.  Opium  should  be  used  to  relieve 
pain,  and  a  nutritious  diet  and  a  judicious  stimulation  are  indicated.  If 
gangrene  occurs,  as  soon  as  a  line  of  demarcation  is  established,  the 
limb  should  be  amputated.  In  the  meantime  antiseptic  poultices  should 
be  applied  and  the  patient's  strength  supported. 

Varices  or  varicose  veins  in  the  extremities  are  at  first  nothing 
but  simple  distended  veins,  which  later,  as  the  result  of  their  distention, 
become  elongated,  tortuous,  and  thickened.  The  same  pathological 
condition  exists  in  varicocele  and  in  hemorrhoids,  but  these  will  be  con- 
sidered under  their  separate  headings  in  another  chapter.  Varicose 
veins  in  the  extremities  are  the  result  of  a  negative  blood-pressure,  in 
the  veins,  brought  about  either  by  direct  pressure  on  the  vessels  them- 
selves or  by  the  simple  weight  of  the  column  of  blood,  which,  not 
being  forced  along,  overcomes  the  natural  elasticity  of  the  vessel-wall 
until  it  becomes  dilated  and  then  stretched.  This  frequently  occurs  in 
persons  who  stand  a  great  deal.  The  blood  is  forced  through  the 
veins  into  the  limbs  largely  by  the  alternate  contraction  and  expansion 
of  the  muscles  pressing  on  the  veins,  so  that  it  causes  a  venous  stasis 
in  the  legs.  Other  exciting  causes  are  abdominal  and  pelvic  tumors, 
effusions  into  the  peritoneal  cavity,  gravid  uterus,  tight  lacing,  garters 
around  the  legs,  and  a  weak  heart.  This  disease  occurs  most  fre- 
quentlv  in  women  and  in  persons  who  have  reached  middlcJife.  The 
varices  begin  by  the  gradual  dilatation  of  the  vein  opposite  the_xabzes, 
where  the  weight  of  the  column  of  blood  is  supported.  This  taking 
place  alternately  on  opposite  sides  of  the  vein  causes  it  to  lengthen, 
and  a  tortuous  vessel  results.  The  knotting  of  the  vein  is  the  result 
of  the  pouching  out  of  the  vessel  opposite  the  valves.  Associated 
with  the  lengthening  and  pouching  of  the  vein  are  inflammatory 
changes ~m~the— wall  of  the-ve55et  As  a  result  ot  this  the  walls 
become  thickened  by  the  exudation  of  inflammatory  products  and  the 
proliferation  of  connective-tissue  cells.  In  this  manner  the  localized 
attacks  of  phlebitis  and  periphlebitis  which  occur  in  connection  with 
varicose  veins  may  be  accounted  for.     Varicose  veins  are  usually  easy 


910 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


to  recognize,  for  they  are  found  chiefly_j£L-the-superficial  vessels  (Fig. 
443).  They  are  seen  as  large,  prominent,  and  tubulous  veins,  com- 
monly on  the  anterior  aspect  of  the  leg,  and  unless  they  are  actively 
inflamed,   are    soft,   easily   compressed,   and   not   painful.      When   the 

trouble  has  existed  for  a  long  time,  owing 
to  the  excessive  thinness  of  the  vessel-wall 
the  vessel  may  suddenly  rupture  and  give 
rise  to  a  serious  and  sornetimes  fatal  hemor- 
rhage.  A  varix  of  the  internal  saphenous 
vein  protruding  through  the  saphenous 
opening  may  easily  be  mistaken  for  femoral 
hernia,  as  it  appears  and  disappears  in  getting 
up  or  lying  down.  It  is  diagnosticated 
from  a  hernia  in  that  pressure  over  the  ring 
does  not  prevent  the  varix  from  reappear- 
ing, while  pressure  easily  controls  a  femoral 
hernia. 

The  treatment  of  varicose  veins  is 
palliative  and  operative.  The  former  fre- 
quently gives  relief  when  the  disease  is 
seen  in  its  early  stages.  Any  preventable 
cause,  such  as  tight  clothing,  garters,  etc., 
must  be  removed.  The  condition  of  the 
circulation  and  of  the  bowels  must  receive 
attention  by  giving  suitable  cathartics.  A 
recumbent  position  with  the  limb  elevated, 
and  gentle  massage  in  an  upward  direction, 
with  the  prohibition  of  sitting  and  standing, 
all  favor  the  venous  circulation,  and  with 
attention  to  the  general  health,  administra- 
tion of  tonics,  and  later  on  suitable  outdoor 
exercise,  assist  in  restoring  the  normal 
tone  of  the  vessel-walls.  Absolute  rest  in 
bed  for  a  few  weeks  is  very  desirable ;  but 
when  this  cannot  be  secured  and  the  patient 
is  allowed  to  be  up,  local  treatment  should 
be  used.  This  consists  of  firm  and  well- 
applied  pressure  distributed  evenly  over  the 
leg  from  the  base  of  the  toes  to  above  the  knee.  The  pressure  must 
be  applied  in  the  morning,  before  the  patient  leaves  the  bed,  while  the 
limbs  are  elevated,  and  is  to  be  removed  at  night  only  after  the  patient 
is  in  bed.  A  simple  bandage  made  from  a  good  quality  of  thin,  firm 
"  domets  "  flannel,  3J  inches  wide,  cut  on  the  bias,  is  inexpensive  and 
easily  made,  and  may  be  efficiently  applied  with  a  slight  amount  of 
experience.  A  better  support  is  a  silk  elastic  stocking  made  to 
measure  and  fitted  accurately  to  the  limb.  Rubber  bandages  are  also 
used  to  a  considerable  extent. 

The  operative  treatment  of  varicose  veins  aims  at  the  obliteration  of 
the  lumen  of  the  vein  or  the  complete  removal  of  the  vessel.  The 
application  of  caustics  to  the  vein  and  the  injection  of  carbolic  acid  are 
dangerous  and  practically  obsolete  methods.     Acupressure  and  subcu- 


FlG.  443. — Varicose  veins. 


DISEASES   OE   THE   BLOOD-VESSELS. 


9II 


taneous  ligature  to  a  vein,  followed  by  compression,  are  rarely  used. 
The  most  satisfactory  method  is  excision  of  portions  of  the  vein  at 
various  points  in  its  course,  although  occasionally  the  greater  part  of 
the  tortuous  vein  may  be  excised.  After  removal  of  the  vein  the 
wound  is  closed  and  primary  union  may  be  obtained.  Trendelenburg1 
advocates  for  varices  of  the  lower  extremity  simply  the  ligation  of  the 
saphenous  vein  where  it  empties  into  the  femoral.  These  operations 
should  be  performed  under  the  strictest  aseptic  conditions,  as  the  tissues 
involved  possess  extremely  poor  resisting  qualities,  and  septic  phlebitis 
and  thrombosis  are  easily  started  up.  It  is  scarcely  necessary  to  say 
that  an  operation  of  this  description  is  required  only  in  those  cases 
which  palliative  treatment  cannot  relieve. 

An  arterial  varix  or  cirsoid  aneurysm  is  a  dilatation  and 
elongation  of  the  arteries  similar  to  the  varices  which  occur  in  the 
veins.  When  the  large  vessels  are  dilated  and  tortuous  it  is  known  as 
a  cirsoid  aneurysm.  It  may  be  congenital,  but  is  usually  acquired  from 
unknown  causes.  It  probably  results  from  some  inherent  stricture  or 
defect  in  the  arterial  wall.  It  occurs  chiefly  in  the  arteries  of  the  scalp, 
face,  neck,  palms  of  the  hands,  and  soles  of  the  feet.  The  diagnosis  is 
easily  established,  as  the  tumor  pulsates  synchronously  with  the  heart, 
and  the  peculiar  tortuous  convoluted  condition  of  the  mass  is  character- 
istic. A  murmur  is  often  heard  over  the  turner.  If  the  tumor  is  in- 
creasing in  size  or  if  inflammatory'  changes  due  to  pressure  are  likely  to 
occur,  with  absorption  of  bone,  ulceration,  and  hemorrhage,  the  tumor 
should  be  excised.  Many  forms  of  treatment  have  been  tried — for 
example,  injections  of  perchlorid  of  iron,  direct  pressure,  application  of 
ligatures  to  the  main  vessels,  galvanopuncture,  electrolysis,  and  subcu- 
taneous ligation.  Excision,  however,  of  the  whole  mass  is  the  most 
satisfactory  method.  The  operation  is  often  serious,  owing  to  the  large 
size  of  the  mass  and  the  quantity  of  blood  that  may  be  lost.  If  the 
tumor  is  not  large  nor  increasing  in  size  and  does  not  cause  pain  or 
annoyance,  an  operation  is  not  called  for. 

Angiomata  are  tumors  composed  for  the  most  part  of  blood-ves- 
sels, but  they  differ  from  arterial  varices  in  that  the  capillaries  are  dilated 
and  the  skin  is  involved.  The  larger  forms  are  known  as  cavernous 
angtomata  (Fig.  444),  from  the  fact  that  the  vessels  are  not  only  dilated 
but  also  obliterated,  and  the  blood  is  contained  in  open  spaces.  These 
tumors  are  usually  congenital,  and  their  cause  is  not  known.  They  are 
found  in  the  liver,  kidney,  spleen,  and  brain,  and  in  bone,  in  the  orbit,  in 
the  larynx,  and  occasionally  in  the  breast  (Fig.  445)-  The  recognition 
of  angiomata,  unless  they  are  deep-seated,  is  usually  not  difficult.  The 
arteries  leading  to  them  are  tortuous  and  dilated  and  visibly  pulsate. 
There  is  often  a  distinct  murmur,  and  by  applying  intermittent  pressure 
alternate  emptying  and  refilling  of  the  tumor  occur.  Treatment  by  electro- 
lvsis,  if  the  growth  is  small,  may  be  successful  and  attended  bylittle 
disfigurement.  If,  however,  the  growth  is  of  considerable  size,  it  should 
be  carefully  dissected  out,  as  in  the  case  of  any  tumor,  ligating  such 
vessels  as  are  necessary,  and  suturing  the  skin  to  secure  primary  union. 

A  nevus  is  a  congenital  disease  of  the  capillaries  or  of  the  veins, 
and  is  frequently  situated  upon  the  face.     When  the  nevus  involves 

^  Beit) age  f.  klin.  Chir.,  1S90,  p.  195. 


912 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 


only  the  capillaries  of  the  skin,  it  appears  as  a  slightly  elevated  area, 
varying  in  size  from  the  head  of  a  pin  up  to  and  involving  the  whole 


'■•-■% 


^ftMf^l^i  fi'.y   :  :  ■     •  ■   ■■•-     -# 

FlG.  444. — Cavernous  angioma  (Warren). 

of  one  side  of  the  face,  and  in  color  varies  from  a  bright  red  to  a  dark 
purple   (Figs.   446,  447).      Nevi   which   cover   considerable   areas  are 


Fig.  445. — Angioma  of  the  lip  and  the  neck  (Warren). 

usually  only  slightly  elevated   above  the   skin,  and  are   often   purely 
cutaneous  (Fig.  448).     Nevi  which  are  markedly  pigmented  are  often 


DISEASES   OF  THE  BLOOD-VESSELS. 


913 


are 


spoken  of  as  "  moles."  They  may  be  of  considerable  size.  They 
not  very  vascular,  and  rarely  show  a  tendency  to  spread  or  to  ulcerate. 
These  moles  are  the  favorite  seat  of  the  development  of  the  melanotic 
forms  of  cancer.      Other  nevi,  especially  of  the  face  and  scalp,  may 


446,  447. — Nevus 


have  a  relative  malignancy  in  that,  if  untreated,  they  slowly  progress 
in  size. 

The  treatment  of  nevi  does  not  need  to  be  operative  unless  there 
is  an  increase  in  their  size  after  careful  continued  examinations  extend- 
ing over  a  length  of  time.  The  small  cutaneous  nevi  may  be  lightly 
touched  with  the  flat  surface  of  an  actual  cautery,  thus  destroying  the 
vessels  with  but  little  pain  and  leaving  only  a  slight  white  scar.     The 


Fig.  448.— Ne 


land  and  the  forearm.     Case  of  L.  M.  Tiffanv. 


nevi  of  larger  size  should  be  treated  by  actually  perforating  them  with 
the  cautery,  by  using  electrolysis,  or  by  the  operation  of  complete 
excision. 

There  seems  to  be  some  danger  of  embolism  after  some  of  the  injection-methods  for 
treating  nevi.  Ninety-five  percent,  alcohol,  however,  5  or  10  minims  once  a  week,  injected 
into  a  nevus  of  the  nose  or  other  prominent  feature,  may  produce  a  marked  paling  effect  up 
to  complete  cure,  without  the  disfigurement  of  operative  scar. 

Aneurysm. — An  aneurysm  is  a  hollow  tumor  filled  with  blood, 

58 


9i4 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY, 


whose  cavity  communicates  with  the  lumen  of  an  artery,  into  which  the 
blood-current  flows  to  and  fro.  The  walls  of  an  aneurysm  may  or  may 
not  be  composed  of  the  coats  of  the  artery,  and  hence  aneurysms  are 
divided  into  true  and  false. 

A  true  aneurysm  is  one  in  which  the  walls  of  the  aneurysmal  sac 
are  formed  by  the  coats  of  the  artery,  at  least  one  of  which  must  be 


Fig.  449. — Sacculated  aneurysm  (Keen  and  White). 


intact.     A  false  aneurysm  is  one  in  which  there  is  no  arterial  coat,  but 
the  blood  is  contained  in  a  sac  of  fibrous  or  other  tissue. 

There  are  many  forms  of  aneurysm  not  of  any  practical  importance, 
but  which  are  recognized  by  different  writers. 

A  diffuse  aneurysm  is  one  which,  as  its  name  implies,  extends  over 
a  considerable  area  of  space  in  the  tissues.  A  traumatic  aneurysm  is 
one  produced  by  direct  trauma  to  an  artery.  The  majority  of  diffuse 
or  traumatic  aneurysms  are  false  aneurysms,  and  the  blood  poured  out 
from  the  artery  is  simply  confined  by  the  surrounding  tissues.  A  dis- 
secting aneurysm  is  one  in  which  there  is  a  partial  rupture  of  the  wall 
of  the  artery,  and  in  consequence  there  is  a  passage  of  blood  between 
its  coats.  A  sacculated  aneurysm  (Fig.  449)  is  a  localized  pouch  bulging 
from  one  side  of  an  artery.  A  fusiform  or  tubular  aneurysm  (Fig.  450) 
is  a  uniform  spindle-shaped  dilatation  involving  all  the  coats  of  the 
artery.  A  hernial  aneurysm  is  one  in  which  one  of  the  coats  of  the 
vessel  becomes  protruded  through  an  outer  ruptured  coat.  An  arterio- 
venous aneurysm  is  a  condition  in 
which  an  abnormal  direct  com- 
munication becomes  established 
between  the  lumen  of  an  artery 
and  that  of  a  neighboring  vein. 

Aneurysm  is  essentially  a  dis- 
ease of  middle  life,  and  occurs  be- 
tween the  ages  of  thirty  to  sixty 
years.  The  most  frequent  seat  of 
the  disease  is  the  thoracic  aorta, 
and  after  that  it  occurs  most  fre- 
quently in  the  popliteal,  the  femoral, 
the  abdominal  aorta,  the  carotid, 
the  subclavian,  the  axillary,  and  the  innominate  artery.  All  of  these 
aneurysms  present  certain  clinical  symptoms  in  common,  and  the  most 


Fig.    450. — Tubulated  or  fusiform    aneurysm 
(Keen  and  White). 


DISEASES    OF   THE   BLOOD-VESSELS.  915 

characteristic  is  the  development  of  an  elastic,  fluctuating,  and  pulsating 
tumor  in  the  course  of  the  artery,  which  may  be  diminished  in  size  by 
exerting  uniform  pressure  on  its  surface.  On  auscultation  an  aneurysmal 
bruit  or  murmur  is  heard  over  the  tumor.  Other  common  symptoms 
are  those  of  pressure  and  weight,  with  dull,  heavy  pains,  diminution 
of  the  volume  of  the  pulse-beat  in  the  vessel  and  its  branches  distally 
from  the  aneurysm,  and  later,  the  absorption  of  the  adjoining  tissues 
from  the  pressure  of  the  aneurysm  (Fig.  451). 


Fig.  451- — Sphygmographic  tracings  of  the  radial  pulse  of  a  patient  with    aneurysm   of  the 
right  brachial  artery:  1,  left  radial  pulse;  2,  right  radial  pulse  (Mahomed). 

Etiology. — The  immediate  cause  of  the  development  of  an  aneu- 
rysm is  usually  an  injury  to  a  previously  diseased  vessel.  This  devel- 
opment in  the  majority  of  cases  is  due  to  the  suddenly  increased 
blood-pressure  from  a  violent  muscular  exertion  or  a  sudden  strong 
emotion. 

The  predisposing  causes  of  aneurysm  are  some  constitutional  dis- 
ease or  habit  which  by  its  long  continuance  has  either  attacked  the 
arterial  coats  in  distinct  areas  or  has  caused  such  general  and  exten- 
sive degeneration  as  to  have  decreased  to  a  large  degree  the  elasticity 
and  resisting  powers  of  the  arterial  walls.  Degeneration  of  the  arterial 
coats  is  the  chief  predisposing  cause  of  aneurysm,  and  it  must  always 
be  present  in  some  form,  except  in  those  cases  due  to  direct  trauma- 
tism. Suppurative  disease  occasionally  invades  the  wall  of  a  vessel, 
and  is  said  to  give  rise  to  aneurysm. 

It  is  a  recognized  truth  that  the  existence  of  arteriosclerosis  is  the 
chief  factor  in  the  causation  of  aneurysm,  and  while  this  disease  does 
not  manifest  itself  till  late  in  life,  it  exists  in  the  diffuse  stage  as  early 
as  forty  years — the  most  common  time  for  aneurysm  to  develop.  As 
a  rule,  patients  ascribe  the  cause  of  aneurysm  to  some  severe  muscular 
effort,  which  is  but  natural. 

As  a  rule,  aneurysms  contain  fluid  blood,  which  readily  transmits 
the  pulsations  of  the  heart  through  its  walls.  In  certain  cases,  how- 
ever— for  example,  in  sacculated  aneurysms,  where  the  outlet  is  small 
and  the  blood-current  is  much  reduced  in  force — the  blood  coagulates 
and  is  deposited  in  successive  laminae  upon  the  wall  of  the  vessel, 
forming  yellowish  thrombi  which  greatly  strengthen  the  wall  of  the 
sac.  If  an  aneurysm  is  left  to  its  natural  course,  with  very  rare  excep- 
tions it  proves  fatal.  The  sac  continues  to  dilate  more  or  less  rapidly, 
and  death  takes  place  from  rupture  of  the  sac,  with  fatal  hemorrhage 
either  externally  or  into  some  one  of  the  cavities  of  the  body.  In 
certain  instances  death  occurs  before  the  sac  ruptures,  owing  to  press- 
ure upon  important  organs,  with  correspondingly  severe  symptoms — 
for  example,  on  the  trachea  and  bronchi,  producing  asphyxia ;  on  the 


gi6  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

esophagus  or  thoracic  duct,  producing  inanition  ;  on  the  spine  in  aortic 
aneurysm,  causing  absorption  of  the  bone  and  meningitis.  The  final 
rupture  may  or  may  not  be  due  to  muscular  strain ;  death  is  not 
always  instantaneous,  but  frequently  occurs  after  several  successive 
hemorrhages. 

The  prognosis  of  aneurysm  of  the  aorta,  the  innominate,  the  sub- 
clavian, and  iliac  arteries  is  usually  fatal,  although  a  kw  cases  of  cure 
have  occurred  in  aneurysms  situated  in  these  vessels.  The  gravity  of 
the  disease  decreases  and  the  success  of  operative  interference  increases 
as  the  location  of  the  trouble  is  removed  from  the  heart.  The  duration 
of  life  in  aneurysm  varies  within  considerable  limits  according  to  the 
condition,  occupation,  and  care  of  the  patient,  as  well  as  the  location  of 
the  disease. 

Treatment. — All  methods  of  treatment  of  aneurysms  are  directed 
toward  obliterating  the  cavity  by  coagulation  of  blood  within  its  sac. 
They  have  been  classified  as  medical  and  surgical.  The  former  com- 
prise those  which  by  rest  in  bed,  restriction  of  food  and  liquids,  and 
administration  of  drugs  aim  to  prevent  increase  in  the  size  of  the  tumor 
and  favor  coagulation  of  the  blood,  by  reducing  the  force  of  the  blood- 
current.  These  methods  have  been  in  use  for  a  very  long  time,  but 
are  now  employed  only  in  those  cases  of  internal  aneurysm  in  which 
operative  methods  are  contra-indicated.  The  details  of  the  so-called 
Tufnell  treatment,  as  proposed  by  Bellingham.1  are  absolute  rest  in  bed, 
a  dry  diet  composed  of  a  very  few  ounces  of  bread  or  farinaceous  food, 
with  a  very  little  fish  or  meat  once  or  twice  a  week,  together  with  a  few 
ounces  of  milk  or  water  daily.  A  number  of  cures  have  been  reported 
from  this  course  of  treatment,  which  requires  great  resolution  and  cour- 
age on  the  part  of  the  patient  to  persist  in  for  the  necessary  length  of 
time,  which  is  usually  two  to  three  months.  An  ice-bag  or  pressure  may 
be  applied  to  the  tumor  itself.  Belladonna,  aconite,  and  veratrum  viride 
are  used  to  assist  in  reducing  the  force  of  the  heart's  action.  Sympto- 
matic treatment  is  necessary  in  almost  all  cases ;  for  pain,  the  bromids, 
phenacetin,  and  opium  are  used  when  necessary.  For  attacks  of  angina 
amyl  nitrate,  nitroglycerin,  and  barium  chloric!  are  indicated.  Iodids 
are  administered,  not  alone  for  their  effect  on  syphilis,  but  because  they 
are  supposed  to  have  a  direct  action  on  the  arteries  ;  and  it  is  claimed 
that  the  tincture  of  iodin  and  the  sodium  salts  are  better  than  the 
potassium  salts.  Potassium  iodid  in  increasing  doses  is  most  frequently 
administered,  and  in  some  cases  a  cure  has  been  apparently  favored  by 
its  action.  It  is  supposed  to  slow  the  action  of  the  heart,  to  lessen  its 
force,  and  to  thicken  the  walls  of  the  aneurysm  by  the  deposition  of 
fibrin.  For  the  purpose  of  inducing  the  coagulation  of  blood  in  the 
aneurysm,  injections  of  solutions  of  iron,  ergot,  tannin,  and  other  drugs 
are  sometimes  made  into  the  sac ;  but  there  is  great  danger  of  the 
formation  of  emboli  attending  this  method  of  treatment,  and  it  there- 
fore should  be  condemned. 

Acupuncture  consists  of  the  introduction  of  several  needles  into  the 
cavity  of  the  sac,  allowing  them  to  remain  several  hours  and  then 
withdrawing  them.  This  favors  coagulation,  but  it  is  not  without 
danger. 

1  Dublin  Medical  Press,  xxvii.,  p.  8l. 


DISEASES   OF  THE   BLOOD-VESSELS.  917 

Galvanopuncturc  is  performed  by  inserting  an  insulated  needle  from 
either  side  of  the  sac,  and  with  the  needles  in  contact  a  galvanic  cur- 
rent is  passed  through  for  several  hours.  This  method  is  open  to  the 
same  criticism  as  the  preceding  measures. 

A  method  devised  by  Macewen,1  known  as  "  needling"  has  for 
its  object  the  formation  of  a  white  thrombus  on  the  inner  surface 
of  the  sac.  It  is  accomplished  by  introducing  under  aseptic  pre- 
cautions long  steel  needles,  and  gently  irritating  with  their  points 
the  entire  inside  lining  of  the  tumor.  The  irritation  should  be  only 
great  enough  to  produce  a  reparative  exudation,  so  that  there  is 
formed  by  successive  needling  a  permanent  thickening  of  the  walls 
of  the  aneurysm.  Two  or  three  needles  are  used  at  the  same  time 
in  a  large  aneurysm,  and  a  number  of  foci  of  repair  are  distributed 
over  the  interior  of  the  aneurysmal  sac.  It  is  especially  applicable 
to  large  sacculated  aneurysms  which  are  inoperable — for  example, 
those  situated  at  the  arch  of  the  aorta.  Cures  have  been  reported 
by  Macewen. 

The  introduction  of  foreign  bodies  into  the  aneurysmal  sac  through 
a  canula  after  puncture  is  another  method  of  treatment  for  large  inop- 
erable aneurysms.  Fine  steel  wire,  horse-hair,  catgut,  and  silk  are  the 
materials  which  have  been  used.  A  number  of  yards  of  the  wire  or 
other  substance  is  introduced  through  a  pointed  canula  in  the  hope  of 
causing  obliteration  of  the  cavity  by  an  engaging  blood-clot. 

This  is  Moore's2  method.  Corradi3  modified  it  by  connecting  the  wire,  after  inser- 
tion, with  the  anode  of  a  galvanic  battery.  Of  23  cases  treated  in  this  manner,  the 
reports  of  which  have  been  collected  with  great  detail  and  analyzed  by  Hunner, '  4  were 
apparently  cured  and  9  were  certainly  made  more  comfortable,  all  of  the  cases  being  so- 
called   "inoperable." 

The  Use  of  Gelatin. — Two  per  cent,  solutions  of  gelatin  have  been 
injected  subcutaneously  in  cases  of  saccular  aneurysms  with  alleged 
success  by  Lancereaux  and  Poulesco.5  Futcher6  deems  the  method 
worthy  of  trial  if  the  patient  presents  himself  before  he  is  in  a  desperate 
condition.  The  procedure  is  apparently  innocuous,  but  is  still  in  the 
experimental  stage. 

Compression. — The  treatment  of  aneurysm  by  compression  is  per- 
haps the  oldest  form  of  treatment,  and,  when  properly  carried  out  and 
persisted  in  for  a  sufficient  length  of  time,  usually  results  in  improve- 
ment, and  often  in  cure.  The  pressure  is  applied  preferably  to  the  car- 
diac side  of  the  tumor,  and  may  be  digital  or  mechanical. 

Digital  pressure  is  more  rapid  and  less  painful  than  mechanical,  but 
it  is  an  extremely  difficult  thing  to  keep  it  up  for  the  necessary  length 
of  time,  which  may  be  twenty-four  to  forty-eight  hours,  with  firm  uni- 
form pressure  under  an  anesthetic.  A  relay  of  assistants  is  necessary 
in  carrying  out  this  method. 

The  use  of  mechanical  or  instrumental  compression  is  not  advised. 
The  method  by  digital  compression,  while  annoying  and  painful  to  the 

1  Lancet,  1S90,  ii.,  1086. 

2  Med.  Chirurg.  Trans.,  London,  xlvii.,  p.  129. 

3  Lo  Sperimentale,  April,  1S79,  p.  445. 

4  Johns  Hopkins  Hospital  Bulletin,   Nov.,  1900,  p.  263. 

5  La  Setnaine  Med.,  1897,  p.  238. 

6 Jour.  Amer.  Med.  Assoc.,  Jan.  27,  1 900,  p.  204. 


pi  8 


INTERNATIONAL    TEXT-BOOK  OF  SURGERY, 


patient,  especially  if  he  be  irritable  and  cannot  bear  pain  well,  is  a  very 
safe  method  of  treatment,  and  no  great  risks  are  involved  in  case  of 
failure.     Under  modern  aseptic  technic  the  method  of  digital  compres- 


I 


i) 


FIG.    452. — Old    operation    of  Antyllus    for 
aneurysm  (Keen  and  White). 


FIG.  453.— Anel's  operation   for   aneurysm 
(Keen  and  White). 


Fig.  454.— Brasdor's  operation  (Holmes).  FlG.  455-— War  drop's  operation   (Holmes) 


G£ 


Fig.  456. — Hunter's  operation  for  aneurysm  (Keen  and  Whitej. 


sion  has  been   lately  superseded  by   direct  operative  measures  (Figs. 
452-456). 

Treatment  by  Ligature. — The  treatment  of  an  aneurysm  by  direct 
ligature  to  the  vessel  is  unquestionably  the  most  satisfactory  method 
when  the  aneurysm  is  situated  so  that  this  can  be  accomplished.  The 
operation  must  be  performed  under  the  strictest  aseptic  precautions,  the 
material  being  either  silk  or  animal  ligature,  and  the  wound  closed  to 
secure  primary  union.  Sepsis,  secondary  hemorrhage,  and  gangrene 
are  the  chief  dangers  to  be  feared  as  the  result  of  operation.  Several 
different  operations  are  in  use — namely,  the  distal  ligature,  the  proximal 
ligature,  and  the  double  ligature.  The  most  common  method  in  use  at 
present  is  to  ligate  the  artery  on  the  proximal  side  at  some  distance 
from  the  tumor,  in  order  that  a  place  which  is  firm  and  free  from  dis- 
ease may  be  secured.  The  double  ligature  of  the  vessel,  with  excision 
of  the  sac  (Antyllus),  is  the  best  operation.  Distal  ligature  may  be 
necessary  on  account  of  the  situation  of  the  disease,  as  when  it  occurs 
in  the  innominate  or  subclavian  arteries.  The  advantage  of  ligation 
over  other  methods  of  treatment  is  its  applicability  in  a  greater  number 


DISEASES    OF   THE   BLOOD-VESSELS.  9I9 

of  cases,  the  greater  likelihood  of  success,  its  comparative  ease  and 
safety,  and  its  painlessness. 

Aneurysm  of  Special  Vessels. — Aortic  Aneurysm. — Aneurysm 
of  the  aorta  may  occur  at  any  point  in  the  chest  or  abdomen,  but  those 
involving  the  arch  of  the  aorta  are  the  most  common.  The  disease  is 
usually  obscured  until  the  dilatation  has  advanced  to  a  point  where 
the  tumor  is  visible  externally,  or  until  the  pressure-symptoms  are  so 
acute  as  to  make  the  diagnosis  possible.  A  pulsating  expansile  tumor 
of  a  very  large  size  in  the  front  of  the  upper  part  of  the  chest,  more 
often  on  the  left  of  the  sternum,  is  characteristic  of  an  aneurysm  of  the 
aortic  arch.  The  very  early  symptoms  are  more  or  less  constant  pain, 
disturbance  of  the  laryngeal  muscles  from  pressure  on  the  recurrent 
laryngeal  nerve,  causing  interference  with  respiration,  interference  with 
deglutition,  and  changed  voice-sounds.  Retardation  of  one  radial 
pulse  and  dilatation  of  the  pupil  on  one  side  are  occasional  symptoms. 
As  the  tumor  increases,  the  symptoms  become  more  severe ;  pain,  loss 
of  sleep,  cough,  and  anxiety  supervene.  Absorption  of  the  contiguous 
tissues  of  the  sternum,  ribs,  and  vertebrae  takes  place,  and  death  results 
from  an  external  rupture  or  more  frequently  from  an  internal  rupture 
of  the  aneurysmal  sac.  The  treatment  of  aneurysm  of  the  aortic  arch 
offers  little  hope  of  success.  A  few  cases  have  been  reported  of  a 
successful  result  from  Macewen's  method,  and  also  from  the  introduc- 
tion of  foreign  bodies  into  the  sac. 

An  aneurysm  of  the  abdominal  aorta  is  rarer  than  one  of  the 
thoracic  aorta.  The  development  of  a  characteristic  pulsating  tumor, 
with  the  presence  of  the  aneurysmal  bruit  in  the  abdominal  cavity,  and 
the  careful  exclusion  of  tumors  of  the  other  abdominal  organs,  is  the 
way  in  which  a  diagnosis  may  be  established.  The  treatment  offers 
very  little  chance  of  cure.  Pressure  by  means  of  a  mechanical  tour- 
niquet may  be  applied,  if  the  location  of  the  tumor  renders  this  possible. 
The  abdominal  aorta  has  been  ligated  a  number  of  times — always, 
however,  with  a  fatal  result. 

An  aneurysm  of  the  iliac  arteries  presents  the  same  symptoms  as 
an  aneurysm  of  the  abdominal  aorta,  except  that  being  situated  lower 
in  the  abdomen  it  may  be  made  out  more  clearly.  The  abdominal 
aorta  has  been  ligated  a  number  of  times  for  iliac  aneurysms.  The 
common  iliac  artery  has  been  ligated  several  times  with  success,  and 
although  this  is  a  critical  operation,  it  promises   relief. 

Femoral  Aneurysm. — The  diagnosis  is  comparatively  easy,  but 
from  the  exposed  position  of  the  vessel  the  aneurysm  is  often  of  trau- 
matic origin,  and  hence  may  be  a  false  aneurysm.  It  may  for  this  reason 
be  mistaken  for  a  psoas  or  inguinal  abscess,  and  care  must  always  be 
exercised  in  operating  in  this  region  in  excluding  an  aneurysm.  A 
femoral  aneurysm  has  been  incised  for  a  psoas  abscess  with  fatal 
results.  An  aspirating  needle  can  always  be  used  in  case  of  obscure 
diagnosis,  and  the  problem  in  this  manner  solved.  Proximal  ligation 
of  the  artery  is  the  best  operation  in  femoral  aneurysms. 

Popliteal  aneurysm  is  one  of  the  more  common  types  of  the  dis- 
ease. Owing  to  the  location  of  the  artery  it  is  peculiarly  liable  to  be 
injured,  especially  by  extreme  flexion  of  the  leg;  and  if  the  vessel  has 
become  weakened  by  pathological  changes,  it  may  readily  become  sub- 


920 


INTERNATIONAL    TEXT-ROOK  OE  SURGERY. 


jcct  to  aneurysmal  dilatation  (Figs.  457,  478).  The  tumor  is  necessarily 
superficial  in  position,  and  therefore  the  diagnosis  is  easy  because  of 
the  characteristic  symptoms.  Proximal  ligation  at  the  apex  of  Scarpa's 
triangle  or  at  Hunter's  canal,  or  preferably  double  ligation  of  the 
artery  with  excision  of  the  sac,  are  the  methods  of  treatment. 


FIGS.  457,  458. — Popliteal  aneurysm. 

An  innominate  aneurysm  is  usually  complicated  by  a  dilatation 
of  the  arch  of  the  aorta,  and  often  of  the  subclavian  and  carotid  arte- 
ries. The  tumor  usually  appears  above  the  sternum,  in  the  inter- 
clavicular notch,  or  to  the  right,  near  the  origin  of  the  sternomastoid 
muscle.  Owing  to  the  short  course  of  the  innominate  artery  and  on 
account  of  its  location,  the  aneurysm  is  usually  a  sacculated  one,  and 
for  this  reason  a  ligature  can  rarely  be  applied  on  the  cardiac  side 
of  the  aneurysm.  For  innominate  aneurysms  several  operations  have 
been  performed — distal  ligation  of  the  subclavian  artery,  ligation  of 
the  right  common  carotid  and  the  right  subclavian  arteries,  or  the  liga- 
tion of  either.  All  of  these  are  very  serious  and  grave  operations,  but 
cures  have  been  reported  from  the  use  of  each.  The  innominate  itself 
has  been  ligated  in  all  30  times,  and  usually  for  subclavian  aneurysm. 
Only  4  of  these  cases  are  reported  as  recoveries.  The  important  step 
in  ligating  the  innominate  artery  is  the  excision  of  the  upper  portion 
of  the  sternum,  which  renders  an  otherwise  difficult  operation  a  com- 
paratively simple  one.  The  operation  under  improved  technic  is 
entirely  justifiable. 


DISEASES   OF   THE   BLOOD-VESSELS.  92 1 

Subclavian  aneurysm  is  most  frequent  in  the  outer  or  third  part 
of  the  vessel  and  on  the  right  side.  It  develops  as  a  pulsating  tumor 
above  the  clavicle  and  outside  the  sternomastoid  muscle.  It  gives  rise 
to  disturbance  by  pressure  on  the  brachial  plexus,  and  it  may  cause 
edema  of  the  arm  and  hand.  Ligature  of  both  the  proximal  and  distal 
sides  have  been  performed,  besides  ligation  of  the  innominate.  Liga- 
ture on  the  proximal  side  of  the  vessel,  followed  by  immediate  ampu- 
tation at  the  shoulder-joint,  has   been  suggested. 

Axillary  aneurysm  is  frequently  of  traumatic  origin,  and  occasion- 
ally occurs  as  the  result  of  an  attempt  to  reduce  old  dislocations  in  a 
patient  with  atheromatous  arteries.  It  often  attains  large  size  from 
looseness  of  the  surrounding  tissues,  and  by  pressure  causes  venous 
obstruction  and  edema,  and  threatens  the  loss  of  the  whole  limb. 
The  axillary  artery  is  rarely  ligated  except  where  it  is  wounded  or  for 
a  small  traumatic  aneurysm.  The  operation  for  idiopathic  aneurysm 
of  the  axillary  artery  is  the  ligation  of  the  third  portion  of  the  sub- 
clavian artery.  If  there  is  a  recurrence  of  pulsation  in  the  aneurysm, 
the  distal  ligation  of  the  axillary  artery  and,  if  necessary,  excision  of 
the  sac  are  indicated. 

Carotid  aneurysm  may  occur  at  either  side  of  the  neck,  and  is 
usually  situated  near  its  bifurcation.  The  symptoms  are  the  typical 
pulsating  tumor,  dyspnea,  vertigo,  difficulty  in  swallowing  and  talking, 
cough,  and  ringing  in  the  ears.  The  diagnosis  is  usually  not  difficult. 
Ligation  on  the  cardiac  side  of  the  common  carotid  is  the  best  method 
of  treatment  when  possible  ;  otherwise,  distal  ligature.  Syncope,  embo- 
lism, and  hemiplegia  occasionally  occur  following  ligation  of  the  vessel. 
There  are  cases  on  record,  however,  in  which  both  common  carotids 
have  been  ligated  in  the  same  person  successfully. 


CHAPTER  XXVIII. 

SURGERY  OF  THE  LYMPHATIC  SYSTEM. 

The  lymphatic  system  is  made  up  of  a  multitude  of  minute  canals 
distributed  over  the  surface  and  throughout  the  substance  of  the  body 
tissues.  These  canals  anastomose  freely  one  with  another  and  unite  to 
form  larger  trunks  which  ultimately  empty  their  contents  into  the  ve- 
nous circulation  through  the  thoracic  and  right  lymphatic  ducts.  Along 
the  course  of  these  canals  at  intervals  lie  the  lymph-glands  :  organs  of 
special  structure,  adapted  to  their  function  of  filtering  and  modifying 
the  lymph  which  is  brought  to  them  by  the  vessels  and  passing  it  on 
to  its  destination.  In  addition  to  these  two  elements  of  the  lymphatic 
system  there  exist  great  cavities  in  the  body,  like  the  peritoneum,  the 
pleurae,  and  the  joints,  which  are  in  direct  communication  with  the 
lymphatic  vessels  and  may  be  regarded  as  reservoirs  of  the  lymph. 

The  distribution  of  the  finer  lymphatic  branches  is  so  minute  that  with  the  microscope 
no  end  to  them  can  be  detected.  The  spaces  between  the  individual  cells  and  fibers 
of  the  connective  tissues  seem  to  lead  directly  to  larger  spaces,  and  these  again  to  others. 
When  the  lymph-space  has  attained  the  proportions  of  a  blood  capillar)'  it  begins  to  show 
a  lining  of  endothelial  cells.  As  it  grows  larger  the  lymph-vessel  presents  the  structure 
of  a  vein — an  inner  lining  of  endothelial  cells,  a  middle  coat  of  delicate  muscle-fibers  and 
elastic  tissue,  and  an  outer  coat  of  connective  tissue.  All  these  layers,  however,  are  far 
more  delicate  than  those  in  veins  of  the  corresponding  size.  Valves  are  more  numerous 
in  the  lymphatics  than  in  the  veins,  and  give  a  characteristic  beaded  appearance  to  the 
larger  trunks.     Anastomoses  are  also  more  numerous  than  in  the  veins. 

The  lymph-glands  or  nodes  which  are  scattered  along  the  course 
of  the  lymphatic  trunks  are  complex  structures  of  the  size  and  shape 
of  a  kidney-bean.  A  number  of  afferent  vessels  open  into  the  periph- 
ery of  each  gland  and  communicate  with  the  sinuses  or  lymph- 
spaces  which  traverse  the  gland  substance.  Each  lobule  or  unit  of 
which  the  gland  is  composed  consists  of  a  group  of  lymphoid  cells 
in  a  delicate  meshwork  of  connective  tissue,  surrounded  by  an  open 
reticular  space  or  sinus  traversed  by  septa  bearing  an  endothelial 
covering.  Each  lobule  is  inclosed  by  a  fibrous  capsule,  and  upon 
this  framework   run  the  blood-vessels  of  the  gland. 

The  lymph  is  a  clear,  watery  fluid  having  the  same  constituents 
as  blood  plasma,  but  with  a  lower  specific  gravity.  It  is  derived  from 
the  blood,  escaping  from  the  blood  capillaries  and  smaller  veins,  and 
carries  certain  of  the  deleterious  substances  thrown  off  by  the  cells 
of  the  body  tissues  as  well  as  any  harmful  foreign  substance  which 
may  be  introduced  from  without. 

The  rate  of  flow  is  much  slower  in  the  lymphatic  vessels  than  in 
the  veins.  It  varies,  too,  according  to  the  muscular  pressure  and 
movements  of  the  limbs,  and  is  modified  to  a  certain  extent  by  the 
force  of  gravity.     The  movements  of  respiration  aid  the  flow  of  lymph 

922 


THE   SPLEEX.  923 

by  suction  toward  the  chest  cavity,  and  the  degree  of  blood  pressure 
may  modify  the  amount  of  lymph  transuded  from  the  blood-vessels 
and  thus  alter  the  rate  of  lymph  circulation.  The  flow  of  lymph  is 
further  stated  to  be  more  active  in  youth  and  to  become  less  abun- 
dant and  more  sluggish  with  the  advance  of  age. 

In  addition  to  the  lymphatic  vessels  and  glands  and  the  great 
lymph  reservoirs  there  are  many  situations  in  the  body  where 
lymphoid  tissue  enters  largely  into  the  structure  of  organs  which 
are  themselves  not  included  in  the  lymphatic  system.  The  tonsils 
and  the  lymphoid  follicles  of  the  intestines  are  examples  of  organs 
of  this  nature,  and  their  pathology  and  surgery  are  described  in  detail 
in  other  chapters.  The  spleen,  however,  which  is  an  organ  belong- 
ing both  to  the  blood  and  to  the  lymphatic  systems,  because  of  the 
character  of  its  pathology  can  best  be  included  with  the  surgery  of 
the  lymphatic  system. 

THE  SPLEEN. 

The  anatomy  of  the  spleen  is  rendered  somewhat  obscure  by  reason 
of  the  marked  and  rapid  variations  in  size  which  it  habitually  under- 
goes in  health  as  well  as  in  disease.  In  adults  the  spleen  is  nor- 
mally from  3  to  5^  inches  in  length  and  from  2  to  3^-  inches  in  breadth 
(Coville).  It  occupies  the  extreme  upper  portion  of  the  abdominal 
cavity  on  the  left  side,  and  is  in  relation  with  the  diaphragm,  kidney, 
stomach,  splenic  flexure  of  the  colon,  and  occasionally  with  the  pan- 
creas. The  spleen  is  usually  completely  invested  with  peritoneum, 
and  is  attached  by  ligaments  and  folds  of  peritoneum  to  the  stomach 
and  kidney,  and  occasionally  to  the  diaphragm.  The  anterior  and  pos- 
terior borders  of  the  spleen  commonly  present  grooves  or  notches 
which  become  of  diagnostic  importance  in  hypertrophy  of  the  organ. 
Accessory  spleens  and  even  multiple  spleens  are  not  uncommon. 

The  surgical  affections  of  the  spleen  may  be  arranged  in  four  prin- 
cipal classes :  Traumatic  lesions ;  displacements ;  inflammatory  dis- 
eases ;  tumors. 

Traumatic  lesions  of  the  spleen  are  of  the  usual  varieties — 
punctured,  incised,  and  lacerated  wounds.  Lacerations  may  occur 
either  with  or  without  a  wound  of  the  abdominal  wall,  and  they  form 
the  greater  portion  of  the  cases  amenable  to  surgical  treatment.  In 
military  surgery,  bayonet  and  gunshot  wounds  are  the  most  frequent 
causes  of  injuries  to  the  spleen,  while  in  civil  life  accidental  falls  and 
crushing  blows  are  more  likely  to  produce  rupture.  Previous  displace- 
ment or  disease  of  the  spleen  seems  to  be  a  predisposing  cause  to 
traumatic  rupture.  The  dangers  of  rupture  or  laceration  of  the  spleen 
are  primarily  those  of  hemorrhage,  and  in  open  or  punctured  wounds 
to  these  are  added  the  dangers  of  infection  and  local  or  general  peri- 
tonitis. The  symptoms  are  also  those  of  hemorrhage  into  the  peritoneal 
cavity,  and  the  effused  blood  can  often  be  recognized  by  the  presence 
of  increased  dulness  in  the  left  flank.  The  treatment  should  be  imme- 
diate laparotomy,  to  arrest  the  hemorrhage.  This  may  be  accomplished 
in  small  wounds  of  the  spleen  by  suture  or  with  the  cautery.  If  more 
severe,  gauze  packing  may  be  inserted  to  control  the  bleeding,  but  in 
the  more  serious  lacerations  the  most  rapid  and  satisfactory  operation 


924  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

is  splenectomy.  The  gravity  of  rupture  of  the  spleen  cannot  well  be 
exaggerated.  Llewerenz  reports  a  mortality  of  86  par  cent,  in  cases 
in  which  no  operation  was  performed,  whereas  by  operation  50  per 
cent,  of  cases  were  found  to  recover. 

Perforating  wounds  of  the  spleen,  either  stab  wounds  or  gunshot 
injuries,  demand  a  thorough  cleansing  of  the  tract  with  either  suture 
or  drainage  of  the  wound.  Should  hernia  of  the  spleen  through  such 
a  wound  occur,  it  should  be  reduced,  but  when  irreducible  or  infected, 
either  ligature  or  cautery  may  be  used  to  resect  the  projecting  portion. 

Displacements  of  the  spleen  are,  as  a  rule,  due  to  trauma  or 
to  enlargement  of  the  organ.  The  ligaments  may  be  elongated  to 
such  an  extent  as  to  permit  of  axial  rotation  of  the  spleen  with 
twisting  of  its  pedicle  and  consequent  strangulation.  "  Wandering 
spleens"  with  elongated  pedicles  are  not  infrequently  reported  and 
are  often  accompanied  by  some  form  of  disease,  as  malaria  or  tuber- 
culosis. 

Treatment  consists  in  palliative  measures  in  the  form  of  pads 
and  belts  or  more  radical  operations.  Splenopexy  or  splenorrhaphy 
is  performed  when  the  spleen  is  replaced  and  sutured.  In  general, 
however,  when  wandering  spleen  is  present  and  the  symptoms  demand 
operative  relief,  splenectomy  is  the  operation  chosen  on  account  of 
the  prevalence  of  more  serious  disease  in  spleens  which  have  thus 
become  displaced. 

Inflammatory  Diseases. — Abscess  of  the  spleen  occurs  in 
multiple  form  in  many  terminal  infections,  and  under  these  conditions 
surgical  interference  is,  of  course,  not  indicated.  Simple  abscess  of 
the  spleen  may  follow  acute  inflammatory  processes  in  the  abdomen, 
as  appendicitis,  or  may  result  from  chronic  infections,  such  as  tuber- 
culosis. Trauma  is  occasionally  a  cause  of  abscess  of  the  spleen,  and 
echinococcus  cysts  may  undergo  a  secondary  infection  and  produce  an 
abscess  of  enormous  size.  Marked  constitutional  symptoms  occur,  and 
the  prognosis  is  grave.  The  treatment  is  that  of  abscesses  elsewhere  in 
the  body, — evacuation, — and  the  operation  must  be  prompt  to  be  of  ad- 
vantage. When  the  abscess  is  small  and  the  spleen  not  too  firmly  attached 
by  adhesions,  the  entire  spleen  maybe  removed.  Hagen  reports  7  cases 
successfully  treated  by  splenectomy.  In  case,  however,  the  abscess  cav- 
ity is  more  extensive,  splenotomy  or  incision  may  be  performed  and  the 
cavity  evacuated  and  drained,  either  through  the  abdominal  cavity  or 
by  resection  of  the  ninth  and  tenth  ribs.  The  latter  method  appears 
to  be  the  safer  one  in  advanced  cases,  by  reducing  the  danger  of 
infection  of  the  peritoneal  cavity  to  a  minimum. 

Chronic  enlargement  of  the  spleen  occurs  in  a  number  of  dis- 
eases, and  is  due  to  hyperplasia  of  the  different  elements  of  the  splenic 
tissue  and  to  connective-tissue  changes.  Such  enlargements  may  cause 
symptoms  from  the  mere  size  and  weight  of  the  organ,  sufficient  to  call 
for  operative  relief.  Among  the  conditions  giving  rise  to  enlargement 
of  the  spleen  those  which  require  special  mention  are  malaria,  leu- 
kemia, and  the  varied  pathologic  changes  which  produce  the  symptom- 
complex  called  splenic  anemia. 

The  spleen  in  cases  of  chronic  malaria  may  attain  enormous  propor- 
tions, and  the   discomfort  and   disability  thus  produced  may  demand 


THE   SPLEEN.  925 

surgical  relief.  Jonnesco  has  been  the  most  radical  operator  in  this 
field,  and  he  considers  that  the  removal  of  the  malarial  spleen  takes 
away  the  most  important  stronghold  of  the  malarial  organisms  and 
allows  the  routine  antimalarial  remedies  to  destroy  them.  The  opera- 
tion is  inadvisable  in  extreme  cachexia  and  in  cases  where  extensive 
adhesions  exist  between  the  spleen  and  the  surrounding  tissues.  The 
mortality  of  splenectomy  for  malarial  spleen  in  the  last  decade  is  vari- 
ously estimated  at  from  15  to  23  per  cent. 

Splenic  Anemia. — The  recent  work  of  Osier,  Sippy,  and  Boviard, 
and  that  of  Harris  and  Herzog,  have  done  much  to  clear  up  the  symp- 
toms and  pathology  of  this  disease.  It  is  a  disease  of  early  adult  life 
or  youth  but  not  of  infancy,  and  consists  of  a  primary  enlargement 
of  the  spleen  and  subsequent  anemia.  The  anemia  is  at  first  of  the 
chlorotic  type,  and  is  shown  by  a  marked  fall  in  hemoglobin.  As  the 
disease  progresses  the  red  corpuscles  also  show  a  marked  diminution 
and  a  severe  type  of  anemia  appears,  approaching  the  characteristics 
of  the  pernicious  type.  General  constitutional  symptoms  appear,  and 
epistaxis  may  occur  or  hemorrhages  from  other  mucous  membranes. 
The  disease  is  not  affected  to  any  extent  by  any  form  of  treatment 
except  by  removal  of  the  spleen,  but  when  this  is  done,  recovery  may 
be  said  to  be  the  rule.  The  pathologic  changes  of  splenic  anemia  are 
peculiar  in  presenting  a  diffuse  proliferation  of  the  endothelial  tissue  of 
the  spleen,  together  with  marked  enlargement  and  connective-tissue 
thickening.  The  endothelial  hyperplasia  is  so  extensive  that  the 
appearances  have  been  taken  by  some  writers  to  indicate  a  new  growth — 
an  endothelioma  of  the  spleen.  The  examination  of  the  blood  is  of 
the  utmost  importance  in  establishing  the  diagnosis,  and  only  by  this 
means  can  the  absence  of  leukemia  be  assured.  A  peculiar  form  of 
splenic  enlargement  associated  with  cirrhosis  of  the  liver  has  been  des- 
cribed by  Banti,  in  which  splenic  enlargement  was  apparently  primary 
and  the  liver  changes  secondary.  This  condition  is  not  clearly  differ- 
entiated from  splenic  anemia,  and  in  fact  true  cirrhosis  of  the  liver 
with  enlargement  of  the  spleen  from  congestion  has  also  been  confused 
with  splenic  anemia  and  has  led  to  errors  of  diagnosis.  Splenectomy 
has  been  performed  in  19  cases,  according  to  Harris'  statistics,  with  14 
recoveries,  and  to  these  may  be  added  a  recent  case  of  Warren's,  making 
20  cases  with  15  recoveries,  or  75  per  cent,  cured. 

Splenic  leukemia  is  another  disease  which  causes  enlargement  of  the 
spleen.  The  splenic  tumor  may  be  the  first  symptom  for  which  the 
patient  seeks  relief,  or,  on  the  other  hand,  grave  anemia  may  develop 
before  the  splenic  enlargement  is  detected.  This  condition  should  be 
sharply  differentiated  from  splenic  anemia  by  the  blood  examination, 
the  blood  of  splenic  leukemia  being  characterized  by  an  increase  of  the 
white  corpuscles  and  the  presence  of  myelocytes,  which  are  absent  in 
splenic  anemia.  This  distinction  is  important  for  the  reason  that 
removal  of  the  spleen  has  heretofore  been  almost  uniformly  fatal  in 
leukemia,  although  giving  such  brilliant  results  in  splenic  anemia. 
Richardson  reports  a  successful  case  of  splenectomy  in  leukemia, 
making  the  fifth  out  of  some  43  cases  operated  upon.  The  excessive 
mortality  in  these  operations  seems  to  be  due  to  a  great  extent  to 
hemorrhage.     At  present  the  operation  cannot  be  recommended. 


926  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Tumors  of  the  spleen  are  more  often  secondary  and  multiple  than 
primary.  Metastatic  tumors,  both  carcinoma  and  sarcoma,  occur  in 
many  cases  as  part  of  a  general  infection,  and  are,  of  course,  inoper- 
able. Primary  tumors  of  the  spleen  occur,  as  sarcoma,  angioma, 
lymphangioma,  fibroma,  and  the  dermoid  and  echinococcus  cysts. 
The  endotheliomata  of  the  spleen  are  not  clearly  differentiated  from 
splenic  anemia,  and  reference  has  already  been  made  to  them  in  the 
consideration  of  that  condition.  Fibroma  and  angioma  are  generally 
of  congenital  origin  when  they  occur  in  the  spleen  and  are  extremely 
rare.  Sarcoma  of  the  spleen  is  more  common  than  the  benign  tumors, 
and  9  cases  are  recorded  by  Hagen  in  which  splenectomy  was  per- 
formed, with  6  recoveries.  This  condition,  however,  cannot  but  be 
regarded  as  a  grave  one. 

The  operation  of  splenectomy,  which  has  been  advised  for  many 
of  the  above  conditions,  is  one  of  the  oldest  operations  in  surgery. 
The  ancients  removed  the  normal  spleen  from  runners  in  order  to  give 
them  greater  speed.  At  present  the  operation  is  done  for  a  number  of 
different  pathologic  conditions  of  the  organ,  which  have  been  already 
enumerated.  The  mortality  has  been  lowered  decade  by  decade,  until 
at  the  present  time  it  can  be  estimated  at  12.2  per  cent.  (Hagen),  this 
being  the  mortality  of  cases  suitable  for  operation  and  in  which  the 
operation  would  at  present  be  advised. 

Several  methods  of  operation  have  been  recommended,  but,  as  a 
rule,  the  following  procedure  may  be  adopted  :  An  incision  may  be 
made  along  the  border  of  the  left  rectus  muscle  from  the  costal  border 
downward,  and  carried  into  the  peritoneal  cavity.  From  this  incision 
a  transverse  incision  to  right  or  left  may  be  made  to  suit  the  needs 
of  the  individual  case.  Adhesions  are  to  be  separated  or  cut  between 
ligatures  when  of  sufficient  size,  and  the  vessels  of  the  hilus  approached 
from  the  inner  side.  In  cases  of  great  enlargement  of  the  spleen  when 
this  mode  of  approach  is  difficult,  separation  of  the  phrenicosplenic 
ligament  will  allow  the  entire  organ  to  be  turned  over  toward  the 
median  line,  with  its  upper  border  pointing  downward  to  the  pubes. 
This  manceuver  brings  forward  the  vessels  of  the  hilus  and  greatly 
facilitates  their  ligation  (Warren).  Owing  to  the  fact  that  the  splenic 
vessels  are  of  large  size  and  of  delicate  structure,  the  utmost  care  must 
be  exercised  in  securing  them.  A  single  ligature  around  the  entire 
mass  may  be  applied,  but  later  each  branch  must  be  secured  and  tied 
separately,  to  guard  against  the  hemorrhage,  which  is  the  most  frequent 
cause  of  death  after  the  operation. 

In  the  greatly  enlarged  spleens  of  anemia  and  malaria  adhesions 
may  be  so  numerous  and  of  such  a  size  as  to  contraindicate  the  removal 
of  the  organ. 

Results  of  Splenectomy. — The  results  of  the  many  operations 
already  reported  show  that  the  spleen  is  not  an  organ  in  anyway  essen- 
tial to  healthy  existence.  A  certain  series  of  phenomena  occur,  how- 
ever, during  the  time  immediately  following  the  operation,  which  are 
practically  constant  in  all  cases,  and  which  may  be  attributed  to  the 
removal  of  the  organ  and  the  loss  of  its  function  to  the  body. 

A  diminution  in  hemoglobin  and  in  the  number  of  red  corpuscles  is 
a  constant  sequel  to  splenectomy  in  animals  as  in  man.     This  diminu- 


LYMPHATIC    VESSELS.  927 

tion  reaches  its  height  two  to  three  weeks  after  the  operation,  and  then 
gradually  disappears. 

An  increase  in  the  number  of  leukocytes  is  also  a  constant  result  of 
splenectomy.  This  leukocytosis  rapidly  reaches  its  maximum,  gen- 
erally about  20,000,  and  then  slowly  declines  to  normal.  The  increase 
is  not  confined  to  the  polynuclear  forms,  but  includes  the  lymphocytes 
and  the  eosinophiles. 

An  elevation  of  temperature,  independent  of  the  condition  of  the 
wound,  has  been  frequently  observed  after  removal  of  the  spleen,  but 
cannot  be  regarded  as  of  constant  occurrence.  Mental  disturbance  and 
changed  disposition  have  rarely  been  observed.  Diminution  of  the 
biliary  coloring-matters  in  the  stools  has  also  been  noted  as  a  conse- 
quence of  the  lack  of  hemoglobin  derivatives  normally  supplied  to  the 
liver  by  the  spleen. 

Accessory  spleens  have  been  found  to  be  present  in  many  persons, 
but  they  are  by  no  means  constant,  and  in  their  absence  the  function 
of  the  spleen  seems  to  be  assumed  by  several  different  tissues.  Evi- 
dence is  given  of  enlargement  of  the  lymph-glands  and  of  the  thyroid 
in  certain  cases  after  splenectomy,  and  in  animals  increased  vascularity 
of  the  bone-marrow  occurs. 


LYMPHATIC  VESSELS. 

The  wide-spread  and  abundant  distribution  of  the  lymphatic  channels 
on  the  surface  of  the  body  exposes  the  lymphatic  system  to  every 
trauma,  trivial  or  great,  which  the  body  undergoes.  No  pin-prick  can 
pierce  the  epidermis  without  opening  up  many  lymphatic  spaces  and 
depositing  in  them  more  or  less  of  the  contamination  of  the  outside 
world.  The  question  of  whether  this  contamination  shall  produce  in- 
fection, or  whether  it  shall  be  overcome  by  the  resistant  fluids  of  the 
body  and  carried  off  by  phagocytes,  is  one  that  is  settled  at  the  point 
of  injury,  in  the  outlying  ramifications  of  the  lymphatic  system. 
When  the  infection  is  too  great  for  the  body  to  overcome,  it  is  through 
the  lymphatic  channels  that  the  septic  process  extends  from  the 
periphery  toward  the  vital  regions  of  the  trunk,  and  ultimately  causes 
death. 

Wounds. — In  subcutaneous  injuries,  and  in  wounds  made  at  opera- 
tion under  septic  conditions,  large  numbers  of  lymphatic  vessels  are 
opened.  In  such  cases,  however,  the  question  of  infection  is  generally 
absent,  and  save  for  the  serous  ooze  which  escapes  from  the  wounded 
lymphatic  vessels,  no  harm  results.  This  oozing  from  wounded  lym- 
phatics is  rarely  sufficient  to  demand  attention,  but  in  special  regions, 
where  many  large  trunks  are  exposed  to  injury,  as  the  axilla  or  groin, 
an  abundant  flow  of  lymph  (lymphorrhagia)  may  occur  to  an  extent 
sufficient  to  embarrass  healing  and  demand  control  by  gauze  packing 
and  firm  pressure. 

The  thoracic  duct  is  occasionally  wounded  in  the  neck  by  stab 
wounds  or  at  operations  in  this  region.  Keen,  Cushing,  and  more 
recently  Allen  and  Briggs  have  made  valuable  contributions  to  the 
literature  of  this  subject.  The  thoracic  duct  rises  3  to  5  J  cm.  above 
the  sternum  as  it  curves  into  the  neck  to  reach  its  outlet  at  the  junction 


928  INTERNATIONAL    TEXT-BOOK  OE  SURGERY. 

of  the  left  subclavian  and  jugular  veins.  The  termination  of  the  duct 
may  be  single  or  multiple,  and  the  number  of  lymphatic  branches 
opening  into  the  duct  in  this  region  vary  to  a  considerable  degree. 
When  the  duct  is  wounded  at  operation  the  escape  of  milky  chyle  may 
be  at  once  detected.  If  the  duct  is  empty,  however,  or  if  it  contain 
merely  lymph,  as  in  the  interval  when  digestion  is  completed,  the  injury 
may  escape  unnoticed  and  become  apparent  only  by  the  subsequent 
collection  of  a  milky  fluid  in  the  wound.  Wounds  of  the  thoracic  duct 
have  heretofore  been  considered  of  grave  significance,  but  this  view  is 
shown  to  be  without  foundation  by  the  number  of  reported  cases  in 
which  suture  or  pressure  were  successful  in  controlling  the  leakage  of 
chyle  and  restoring  the  function  of  assimilation.  Many  cases  of  sup- 
posed wounds  of  the  duct  are  in  all  probability  injuries  to  one  of  sev- 
eral terminal  branches  or  to  one  of  the  larger  lymphatic  trunks  near  to 
its  opening  into  the  duct  rather  than  to  the  duct  itself.  Suture  of  the 
wound  in  the  duct  has  been  performed  successfully,  and  in  a  number 
of  cases  packing  and  pressure  have  been  sufficient  to  control  the 
escape  of  chyle.  Extensive  leakage  from  the  duct  is  accompanied  by 
rapid  loss  of  weight,  but  nutrition  can  be  maintained,  as  suggested  by 
Allen,  by  the  administration  of  albumins  and  carbohydrates  until  the 
wound  has  had  an  opportunity  to  heal.  In  operations  in  this  region  of 
the  neck  the  surgeon  must  bear  in  mind  the  dangers  of  this  complica- 
tion and  exert  the  utmost  care  to  avoid  opening  the  duct  or  including 
it  in  a  ligature. 

Acute  I/ytnphangitis  [Angioleucitis). — Acute  inflammation  of  the 
lymph-vessels  may  be  divided  into  two  classes — those  of  the  peripheral 
system  and  those  of  the  lymphatic  trunks. 

Peripheral  (reticular)  lymphangitis  occurs  probably  to  a  certain 
extent  in  every  wound  penetrating  the  soft  parts,  but  rarely  assumes 
such  proportions  as  to  acquire  diagnostic  or  therapeutic  importance. 
The  type  of  peripheral  lymphangitis  of  a  pronounced  form  is  erysipelas, 
the  full  consideration  of  which  has  been  taken  up  in  a  special  chapter. 

"  Tubular  "  Lymphangitis. — Extension  of  a  septic  process  from  the 
periphery  has  already  been  stated  to  take  place  chiefly  through  the 
lymphatic  trunks.  This  extension  may  be  comparatively  slow,  and 
there  may  be  an  extreme  degree  of  reaction  on  the  part  of  the  vessels, 
or  it  may  occur  with  almost  lightning-like  rapidity.  The  virulence  of 
the  infection,  together  with  the  constitutional  resistance  of  the  indi- 
vidual, seem  to  be  the  determining  factors  of  this  rapidity  of  progress. 
When  resistance  is  strong,  many  leukocytes  are  poured  out,  the  vessels 
are  blocked  by  coagulation,  and  extension  occurs  slowly,  if  at  all. 
When  resistance  is  weakened  or  the  virulence  of  infection  is  great,  few 
leukocytes  appear,  the  vessels  remain  patent,  and  extension  in  the  line 
of  the  lymph-current  is  not  obstructed.  The  causes  of  tubular  lym- 
phangitis are  bacterial,  and,  as  a  rule,  the  streptococcus  is  the  organism 
present,  although  the  staphylococcus,  the  bacillus  of  Ducrey  (chan- 
croid), and  other  bacteria  are  occasionally  found.  Infection  is  often 
from  a  slight  and  apparently  trivial  wound — a  pin-prick  or  a  scratch  or 
cut  at  the  autopsy  table  or  during  a  surgical  operation.  Workers  in 
animal  tissues,  where  decomposition  may  occur,  are  peculiarly  liable  to 
these  infections.     Diabetes  and  other  constitutional  diseases  are  said  to 


LYMPHATIC    VESSELS.  929 

be  predisposing  causes.  All  degrees  of  rapidity  of  progress  occur,  and 
often  a  period  of  incubation  exists  between  the  introduction  of  the 
infection  and  the  appearance  of  symptoms.  In  other  cases  (galloping 
lymphangitis)  no  such  latent  period  is  present,  but  the  symptoms  begin 
at  once  and  make  such  rapid  strides  that  their  progress  can  be  noted 
from  moment  to  moment. 

The  symptoms  are  local  pain,  the  development  of  red  lines  along  the 
course  of  the  lymphatic  trunks,  and  the  constitutional  symptoms  of 
fever  and  chills,  nausea  and  headache,  which  accompany  any  virulent 
infection.  The  red  lines  are  due  to  inflammation  of  the  lymphatic  ves- 
sels and  of  the  tissues  surrounding  them — a  perilymphangitis  which 
can  occasionally  be  felt  as  an  indurated  cord  beneath  the  skin. 

The  lymph-glands  in  the  course  of  the  infection  will  take  part  in 
the  general  acute  inflammatory  process,  and  the  swelling  and  tenderness 
of  an  axillary  or  inguinal  gland  may  indeed  be  the  first  symptom  to 
point  to  the  infection. 

The  progress  of  the  disease  may  vary.  Localization  may  occur  at 
the  original  point  of  injury  and  an  abscess  develop.  Suppuration 
along  the  course  of  the  lymphatic  trunks  may  occur,  with  multiple 
superficial  abscesses,  or  a  deep  phlegmon  may  be  produced  when  the 
deeper  trunks  are  mainly  involved.  Abscesses  of  the  lymph-glands 
in  the  course  of  the  infection  are  not  uncommon,  and  finally  either 
the  entire  process  may  resolve  without  outside  interference,  or,  on 
the  other  hand,  the  surgeon  may  be  powerless  to  arrest  the  upward 
progress  of  the  disease,  and  death  may  occur  with  symptoms  of  an 
intensely  rapid  septicemia  or  with  the  more  slowly  developed  symptoms 
of  pyemia. 

The  treatment  of  this  condition  must  be  prompt  to  be  effective. 
Removal  of  the  cause,  by  enlargement  and  thorough  cleansing  or 
cauterization  of  the  wound  of  entrance,  is  the  first  requisite  when  the 
case  is  seen  immediately,  and  may  well  be  done  in  every  case.  General 
supportive  and  stimulating  treatment,  and,  above  all,  alcohol,  must  be 
supplied.  Amputation  of  the  infected  part  may  be  indicated  at  once 
in  cases  of  severe  infection,  or  later  when  deep  phlegmonous  inflam- 
mations occur.  The  application  of  antiseptic  poultices  and  baths  will 
be  of  service.  When  local  abscesses  form,  either  superficial  or  deep, 
they  should  be  freely  opened  and  evacuated  without  delay.  The  prog- 
nosis depends  almost  entirely  on  the  virulence  of  the  infection,  but 
acute  advancing  lymphangitis  should  never  be  regarded  as  other  than 
a  serious  disease. 

Chronic  lymphangitis  may  result  from  the  gradual  subsidence 
of  an  acute  process,  or  may  be  produced  by  agents  such  as  filaria, 
cancer,  or  the  tubercle  bacillus.  Treatment  of  this  condition  is  rarely 
necessary.  The  blocking  of  the  lymphatics  by  actual  growth  of 
carcinoma  cells  sometimes  produces  lymph-stasis  in  the  area  involved, 
and  actual  injection  specimens  of  the  lymphatic  vessels  are  occasionally 
produced  by  the  malignant  growth. 

Filaria — One  specific  and  peculiar  cause  of  chronic  inflammation 
of  the  lymphatic  vessels  is  the  filaria  sanguinis  hominis.  This  organ- 
ism is  a  worm  of  minute  size,  which  makes  its  home  in  the  lymphatic 
trunks  of  the  human  host,  and  by  its  presence  and  the  discharge  of  its 


93° 


INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 


ova  produces  inflammation  and  obstruction  of  the  lymph-channels. 
The  disease  is  endemic  in  tropical  countries,  and  occasionally  occurs  in 
the  southern  United  States.  The  parent  worms  are  said  to  be  ingested 
with   drinking-water,  and  make  their  way  into  the  lymphatics  of  the 

lower  abdomen.  Here  they  take 
up  their  abode  and  engage  in  the 
prolific  reproduction  for  which  they 
are  remarkable.  The  young  filariae 
are  poured  out  into  the  lymph-chan- 
nels and  pass  from  them  into  the 
blood,  this  process  occurring  gener- 
ally at  night.  A  positive  diagnosis 
may  be  made  by  the  recognition  of 
the  active  embryonic  filariae  in  a  fresh 
specimen  of  the  blood. 

The  symptoms  of  filarial  disease 
are  not,  however,  those  of  lymphan- 
gitis, but  are  the  symptoms  of  its 
sequelae  —  the  obstruction  of  the 
lymph-channels.  This  obstruction  is 
manifested  by  a  lymph-stasis  in  one 
of  several  regions  of  the  body  and  a 
subsequent  enlargement  of  the  part 
to  such  proportions  as  to  justify  the 
common  name  applied  to  the  disease 
— elephantiasis.  The  lymphatics  of 
the  abdomen  and  of  the  genitalia  are, 
as  a  rule,  the  favorite  habitat  of  the 
filaria,and  elephantiasis  of  the  scrotum 
(lymph-scrotum)  and  labium  and  of 
the  lower  extremities  are  the  most 
common  forms  of  the  disease.  Fever, 
nausea,  and  pain  of  an  intermittent 
character  are  occasionally  observed 
at  the  onset.  The  part  increases 
slowly  in  size  with  the  collection  of 
lymph  in  the  obstructed  channels. 
The  skin  becomes  sodden  and  thick- 
ened and  loses  its  recuperative  power; 
slight  excoriations  persist  as  shallow 
ulcerations  and  fissures,  from  which 
the  stagnant  lymph  exudes  abun- 
dantly (lymphorrhea).  Enormous 
tumors  of  the  scrotum  and  labium 
result,  and  the  legs  may  become  so  enlarged  as  to  interfere  to  a  great 
extent  with  locomotion. 

False  elephantiasis  is  the  name  applied  to  certain  cases  of  lymphatic 
obstruction  which  are  due  not  to  the  filaria,  but  to  other  causes, 
such  as  trauma  or  the  pressure  of  tumors  upon  the  lymphatic 
trunks.  The  degree  of  enlargement  of  the  affected  parts  rarely  at- 
tains the  enormous  proportions   of  the   true   or   filarial   elephantiasis. 


459.— Lymph- 
elephantiasis 


rotum  1  Fiji  Islander) : 
ninety  pounds. 


L  \  MP  HA  TIC    VESSELS. 


93* 


The  false  form,  however,  is  that  most  often  met  with  in  northern  or 
temperate  climates. 

Chyluria. — The  presence  of  chyle  in  the  urine  may,  like  elephanti- 
asis, be  due  to  the  filaria,  or  to  other  conditions  causing  obstruction  to 
the  lymphatics.  In  this  condition  a  communication  exists  between  the 
abdominal  lymphatics  and  the  urinary  passages.  The  urine  is  milky 
white  when  passed,  or  it  may  also  contain  blood.  Chyluria  is  generally 
an  intermittent  affection,  and  may  exist  in  this  way  for  many  years 
without  serious  effects.  Chylous  ascites  is  another  condition  which 
may  be  produced  by  the  filaria  or  other  causes  of  lymphatic  obstruc- 
tion, when  communication  is  established  between  the  lymphatic  trunks 
and  the  peritoneal  cavity. 

The  treatment  of  elephantiasis  and  of  chyluria  must  be  mainly 
surgical.  Systemic  and  symptomatic  medical  treatment  can  be  only 
palliative,  and  the  point  of  obstruction  or  of  communication  must  be 
sought  and  removed  in  order  to  obtain  permanent  relief  from  the  dis- 
ease. In  cases  of  true  filarial  disease,  operative  removal  of  the  glands 
in  the  groin  in  which  the  adult  parasites  were  present  has  given  satis- 
factory results.  When  lymph-scrotum  has  reached  such  proportions 
as  to  be  a  burden,  amputation  may  be  performed. 

I,ymphangiectasis  ;  lymphangioma.— Any  diffuse  dilatation 
of  preexistent  lymphatic  vessels  may  properly  be  called  lymphangieo 


FlG.  460. — Cavernous  lymphangioma  of  the  axilla  of  congenital  origin  (Warren). 


tasis.     A  tumor  consisting  of  lymphatic  vessels  or  any  circumscribed 
dilatation  is  termed  a  lymphangioma. 

The  dilatation  may  occur  in  the  superficial  network  of  lymphatics 
or  may  affect  the.  larger  trunks.     In  the  one  case  a  lymphatic  naevus  is 


932  intkrxatjox.il   textbook  of  surgery. 

produced,  similar  in  every  way  to  true  naevi,  and  congenital  in  origin. 
In  the  other  case,  single  or  multiple  cysts  or  cavernous  structures  may 
be  produced,  which,  as  a  rule,  have  been  given  special  names  accord- 
ing to  their  situation.  The  neck,  tongue,  and  lip  are  most  frequently 
involved. 


FlG.  461. — Cavernous  lymphangioma  of  neck  and  axilla  in  a  young  woman  (Homan's  case). 

Macroglossia. — Obstruction  to  the  lymphatics  of  the  tongue  pro- 
duce the  condition  known  by  this  name.  The  obstruction  maybe  con- 
genital, or  it  may  be  due  to  some  inflammatory  or  traumatic  obstruction 
in  later  life.  Congenital  cases  are  attributable  to  the  same  causes 
acting  in  embryonic  life  or  to  developmental  defects.  The  tongue  be- 
comes enlarged,  and  although  the  disease  is  in  itself  not  painful,  the 
continual  enlargement  soon  prevents  closure  of  the  lips  and  jaw, 
the  mucous  membrane  becomes  dry  and  fissured,  and  a  serious  con- 
dition results.  The  point  of  obstruction  can  rarely  be  determined. 
Operative  treatment  consists  of  resection,  or  puncture  and  scarification 
with  the  cautery. 

Macrocheilia  is  a  lymphangiectasis  of  the  lymphatics  of  the  lip. 
Its  symptoms  and  treatment  are  much  the  same  as  those  of  macro- 
glossia. 


LYMPHATIC   GLANDS.  933 

Cystic  hygroma  is  a  tumor  of  the  deep  lymphatics  which  occurs 
most  frequently  in  the  neck,  and  occasionally  in  other  parts  of  the 
body.  The  tumor  is  of  the  cavernous  type,  and  is  made  up  of  a  mass 
of  intercommunicating  cysts  and  spaces,  with  delicate  walls,  containing 
a  clear  limpid  fluid  of  the  character  of  lymph.  The  obstruction  to  the 
lymphatic  channels  is  usually  congenital.  Removal  of  the  tumor  by 
operation  is  the  only  treatment. 

LYMPHATIC  GLANDS. 

Acute  Adenitis. — The  function  of  the  lymph-gland  is  to  collect 
the  lymph  and  strain  it  of  deleterious  substances  before  passing  it  on 
to  its  ultimate  destination  in  the  blood.  In  connection  with  this  func- 
tion abundant  opportunity  for  infection  and  inflammation  of  the  lymph- 
glands  is  afforded.  A  period  of  hyperemia  of  the  gland  is  the  first 
stage  of  an  acute  adenitis,  then  cellular  exudation  and  hemorrhage,  and 
ultimately  abscess  or  resolution,  or,  as  occurs  more  frequently,  subsi- 
dence into  a  chronic  adenitis. 

Acute  adenitis  occurs  as  the  result  of  acute  lymphangitis,  and,  in 
fact,  accompanies  every  septic  process  of  much  severity.  It  may  be 
brought  about  by  a  great  variety  of  bacteria  or  their  toxins,  and  be- 
comes the  main  feature  of  the  disease  in  a  few  special  infections,  as,  for 
example,  that  of  chancroid  or  the  bubonic  plague.  Acute  adenitis  in 
these  diseases  generally  occurs  in  the  inguinal  lymph-glands  and  passes 
by  the  name  of  bubo. 

The  treatment  of  acute  adenitis  consists  of  hot  applications,  flaxseed 
poultices,  and  rest.  If  resolution  is  delayed,  counterirritation  may  be 
of  benefit.  When  abscess  occurs,  it  should  be  opened  and  the  cavity 
thoroughly  cleansed.  Abortive  treatment  has  not  been  successful  in 
the  hands  of  the  majority  of  surgeons.  Healing  is  tedious,  but  rarely 
complicated.  The  delayed  healing  of  abscesses  having  origin  in  lym- 
phatic glands  is  frequently  due  to  the  fact  that  suppuration  may  be 
well  established  in  foci  at  the  periphery  of  the  gland,  while  yet  the 
central  portions  of  the  gland  substance  are  intact.  The  sloughing  and 
discharge  of  these  later  infected  portions  of  the  gland  are  the  cause  of 
much  vexatious  delay  in  recovery,  and  their  thorough  removal  with 
scissors  and  curette  will  greatly  expedite  the  collapse  and  closure  of  the 
wound. 

Chronic  Adenitis. — Chronic  and  subacute  inflammations  of  lymph- 
glands  are  of  frequent  occurrence,  and  maybe  due  either  to  a  previous 
acute  adenitis  which  has  subsided,  or  to  the  presence  of  irritative  sub- 
stances or  bacteria  which  manifest  their  presence  by  a  slower  process 
and  one  of  long  duration.  Hereditary  tendencies  and  constitutional 
conditions  play  a  part  in  the  predisposition  to  chronic  adenitis,  and  the 
now  obsolete  term  of  "scrofulous"  was  often  applied  to  persons  exhibiting 
this  tendency. 

The  most  frequent  causes  of  chronic  adenitis  are  tuberculosis  and 
syphilis,  although  other  bacteria  and  their  toxic  products  may  give  rise 
to  the  same  condition. 

Simple  non-tubercular  chronic  adenitis  is  a  condition  generally  met 
with  in  children,  and  most  often  in  the  cervical  glands.     It  is  attributed 


934  INTERNATIONAL    TEXT-BOOK   OF  SURGERY. 

to  tonsillar  and  faucial  absorption.  The  glands  become  enlarged  and 
hard,  and  may  undergo  fatty  degeneration.  Secondary  infections  may 
occur  and  abscesses  result,  or  the  entire  process  may  subside,  leaving 
a  hard  mass  which  eventually  contracts  and  gives  rise  to  no  further 
symptoms.  Treatment  is  confined  to  hygiene  and  constitutional  meas- 
ures, and  the  avoidance  of  further  irritation  by  attention  to  any  disease 
of  the  nose  or  throat  or  of  the  teeth. 

Tubercular  adenitis  is  one  of  the  most  common  diseases  of  the 
lymphatic  glands.  Children  are,  as  a  rule,  most  commonly  affected, 
but  the  disease  is  by  no  means  confined  to  early  life.  The  lymph- 
glands  in  all  parts  of  the  body  may  be  involved,  but  those  of  the  neck 
externally,  and  of  the  mediastinum  and  mesentery  of  the  internal  groups 
are  most  commonly  affected. 

The  infection  is  rarely  in  a  single  gland.  The  individual  glands  are 
enlarged  and  at  first  hard.  Nodules  and  diffuse  areas  of  tubercular 
tissue  are  scattered  through  their  substance.  Tubercles  and  giant- 
cells  are  frequently  seen.  Later  caseation  and  liquefaction  occur.  At 
this  stage  of  the  disease  secondary  infection  may  occur  and  an  abscess 
form  ;  or  the  resistance  of  the  tissue  may  cause  the  process  to  be  en- 
capsulated, and  absorption  or  calcification  of  the  liquefied  tissue  may 
take  place.  In  young  adults,  when  the  process  is  general,  proliferation 
may  be  active  and  liquefaction  delayed,  and  in  such  cases  the  diagnosis 
from  Hodgkin's  disease  may  be  most  difficult. 

Treatment. — Hygiene  and  constitutional  measures  are  the  main 
factors  in  the  treatment  of  this  disease,  together  with  attention  to  the 
condition  of  the  throat  and  teeth.  Many  cases  fail  of  cure  for  lack  of 
this  attention.  Operative  removal  is  advised  by  many  surgeons  as  a 
routine  treatment,  and  in  adults  this  procedure  can  be  recommended 
when  performed  early,  as  giving  less  scar  and  less  danger  of  general 
tubercular  infection  than  palliative  treatment.  In  children,  however, 
constitutional  treatment  often  arrests  the  disease,  and  operation  may 
properly  be  reserved  for  the  more  obstinate  cases.  When  abscess 
occurs,  a  small  incision  is  to  be  made,  and  the  partially  disorganized 
gland  tissue  thoroughly  curetted  out.  General  miliary  tuberculosis 
or  some  other  form  of  fatal  tubercular  disease  results  in  a  very  small 
proportion  of  cases,  and  more  often  from  infection  of  the  mediastinal 
and  bronchial  glands  than  from  those  of  the  neck  and  axilla.  When 
the  retroperitoneal  and  mesenteric  glands  are  involved,  operation  is  indi- 
cated and  has  given  good  results. 

Syphilis  causes  a  chronic  adenitis  of  a  peculiarly  fibrous  nature,  with 
slight  increase  in  the  size  of  the  gland  and  a  painless  course.  Gumma 
also  occurs  in  lymph-glands  and  does  not  differ  from  gumma  in  other 
regions. 

*"  The  predisposition  of  carcinoma  to  form  metastases  in  the  lymph- 
glands  of  the  nearest  system  of  lymphatics  is  well  recognized.  Such 
metastases  are  due  to  the  transfer,  through  the  lymphatic  vessels,  of 
minute  fragments  or  cells  of  the  carcinomatous  growth.  Glands  in- 
fected with  carcinoma  receive  the  infection,  as  a  rule,  in  the  periphery. 
From  this  point  the  tumor-cells  gradually  invade  the  tissue  of  the 
gland,  replacing  and  displacing  the  normal  lymphoid  tissues.  Extension 
through  the  capsule  of  the  gland,  along  the  lymphatic  vessels,  and  into 


LYMPHATIC   GLANDS.  935 

the  surrounding  tissues  soon  occurs.  When  degeneration  or  suppura- 
tion occurs  in  the  primary  tumor,  simple  adenitis  may  occur,  and  the 
lymph-glands  may  be  enlarged,  without  actual  metastatic  growth  of 
carcinomatous  cells.  Such  a  condition  must  be  borne  in  mind  by  the 
surgeon  in  estimating  the  extent  of  a  given  carcinoma  growth,  although 
in  any  case  of  carcinoma  an  enlarged  gland  must  be  supposed  to  be  a 
metastatic  growth  until  the  contrary  is  proved.  Sarcoma  occasionally 
gives  metastases  in  lymph-glands,  although  by  no  means  so  frequently 
as  carcinoma.  Its  manner  of  growth,  however,  when  once  trans- 
planted, is  much  the  same. 

Primary  tumors  of  lymph-glands  are  of  comparatively  rare 
occurrence,  and  their  differentiation  and  nomenclature,  even  at  the 
present  time,  are  unsatisfactory  and  obscure.  Lymphatic  leukemia, 
Hodgkin's  disease,  and  sarcoma  are  the  diseases  which  will  be  con- 
sidered under  this  heading. 

Lymphatic  Leukemia. — The  pathologic  changes  characteristic 
of  lymphatic  leukemia  are  two  in  number — enlargement  of  the  lym- 
phoid tissue  of  the  body  and  increase  in  the  number  of  the  lymphocytes 
in  the  blood.  The  lymph-glands  take  part  in  the  general  enlargement 
and  increase  in  size  to  such  an  extent  as  to  form  tumor  masses  in  the 
neck,  axilla,  and  in  other  regions.  Histologically  the  structure  of  the 
lymph-gland  is  maintained  in  the  enlargements,  and  the  glands  remain 
freely  moveable  and  discrete.  This  process  is  properly  a  hyperplasia 
rather  than  an  actual  tumor-formation.  The  lymphoid  tissues  else- 
where take  part  in  this  hyperplasia  and  appear  as  nodules  in  the  intes- 
tine, spleen,  and  liver.  The  course  of  the  disease  ma}-  be  slow,  or,  on 
the  other  hand,  so  rapid  as  to  suggest  an  infective  process.  Anemia 
is  a  marked  symptom  and  the  diagnosis  depends  upon  the  blood 
examination.  Treatment  is  of  little  benefit.  Operative  treatment  is 
not  recommended. 

Hodgkin's  Disease  {Pseudoleukemia;  Malignant  Lymphoma; 
Adenie  ;  Lymplwsarcoma). — This  disease  involves  the  lymphoid  tissues 
of  the  body  in  its  early  stages  in  much  the  same  manner  as  leukemia; 
and  thus  the  name  of  pseudoleukemia  is  derived. 

The  disease  begins  with  a  gradual  onset  and  one  or  more  super- 
ficial glands  become  enlarged.  The  cervical  region  is  generally  first 
attacked.  The  anemia  may  be  quite  as  marked  as  in  lymphatic 
leukemia,  but  no  increase  of  leukocytes  occurs.  Extension  takes 
place  to  other  systems  of  lymphatic  glands,  and  may  ultimately 
involve  the  lymphoid  tissues  generally  throughout  the  body.  Histo- 
logically the  early  stages  of  the  disease  show  only  a  hyperplasia  of 
the  entire  complicated  lymph-gland  structure,  and,  as  is  found  in  leu- 
kemia, the  sinuses  remain  open  and  the  glands  are  discrete.  Later, 
however,  the  appearance  is  that  of  a  malignant  growth,  made  up  of 
lymphoid  cells  in  their  proper  reticulum.  This  growth  infiltrates 
the  gland-capsule,  invades  surrounding  tissues,  and  ultimate!}'  pro- 
duces metastases  in  other  parts.  This  is  the  true  lymphosarcoma  or 
malignant  lymphoma.  A  hard  and  soft  form  of  the  disease  have  been 
distinguished,  depending  on  the  amount  of  reticulum  present.  The 
individual  glands  become  welded  together  into  large  masses  in  the 
neck  and  mediastinum,  which  may  obstruct  the  trachea  and  vessels. 


936  INTERNATIONAL    TEXT-BOOK  OF  SURGERY. 

Degeneration  occurs  at  times,  and  suppuration  may  result  from  skin 
involvement. 

It  is  undoubtedly  true  that  many  cases  of  general  tubercular  aden- 
itis have  been  mistaken  clinically  for  Hodgkin's  disease,  but  histologi- 
cally the  difficulties  of  distinction  should  not  be  so  great,  and  in  this 
connection  the  removal  of  a  specimen  of  the  tissue  for  diagnosis  may 
be  of  inestimable  service.  The  treatment  of  Hodgkin's  disease  is 
mainly  symptomatic  and  constitutional.  Arsenic  is  of  the  most  value. 
Operative  removal  of  the  affected  glands  has  not  been  successful  in 
preventing  the  progress  of  the  disease  when  once  it  was  well  established, 
but  in  early  cases  it  should  be  attempted. 

Sarcoma. — From  the  lymph-glands,  as  from  any  other  tissue  of 
mesoblastic  origin,  sarcoma  may  arise.  To  the  peculiar  sarcoma  which 
repeats  the  type  of  lymphoid  tissue  (lymphosarcoma,  or  Hodgkin's 
disease),  reference  has  been  made.  In  addition  to  lymphosarcoma, 
sarcomata  of  many  varieties  have  been  described  as  taking  their  origin 
in  the  tissues  of  the  lymph-gland.  They  differ,  however,  in  no  respect 
from  sarcomata  in  other  situations  ;  they  arise  from  one  gland,  not 
from  a  system  of  glands,  and  they  may  be  made  up  of  large  or 
small  round  cells  or  spindle  cells,  or  may  be  of  the  type  of  mixed- 
cell  sarcoma.  Endothelial  tumors  and  angiosarcoma  have  also  been 
described.  The  treatment  of  sarcoma  arising  in  lymph-glands  is  the 
same  as  that  of  sarcoma  elsewhere,  and  operation  must  be  done  early 
to  be  of  benefit. 


INDEX. 


ABBES    method  of  dividing   posterior   nerve- 
roots  for  neuralgia,  881 
Abdominal  actinomycosis,  204 

aorta,  aneurysm  of,  919 
ligature  of,  327 

muscles,  rupture  of,  768 
Abnormal  mobility  in  fractures,  508 
Abrasions  of  the  skin,  healing  of,  126 
Abscess,  67 

brain,  812 

treatment,  813 

cervical,  73 

diagnosis,  74 

dorsal,  in  Pott's  disease,  847 
treatment,  851 

gluteal,  in  Pott's  disease,  847 

iliac,  in  Pott's  disease,  847 

iliopsoas,  in  Pott's  disease,  847 

in  hip-disease,  treatment,  734 

in  Pott's  disease,  846 
treatment,  851 

leukocytosis  in,  81 

lumbar,  in  Pott's  disease,  847 
treatment,  851 

of  scalp,  785 

of  skin,  67 

of  spleen,  924 

palmar,  72 

pathology  of  the  blood  in,  81 

perinephritic,  73 

postesophageal,  in  Pott's  disease,  846 

postpharyngeal,  in  Pott's  disease,  846 
treatment,  851 

psoas,  in  Pott's  disease,  847 
treatment,  851 

subfascial,  71 
Absorption  of  ligatures,  138 
Acardiac  fetuses,  501 

Accident  wounds,  aseptic  treatment  of,  295 
A.  C.  E.  mixture,  444 

administration  of,  464 
Accessory  spleens,  927 
Acetabulum,  fracture  of,  573 
Achillodynia,  712 
Acromegaly,  698 

treatment  of,  698 
Actinomyces,  201 
Actinomycosis,  201 

abdominal,  204 

atria  of  infection  in,  202 

bacteriology,  36 

course,  202 

diagnosis,  205 

faciocervical  form  of,  202 

gross  pathological  anatomy  of,  202 

history  of,  201 

minute  anatomy,  201 

pulmonary  localization,  204 

symptoms,  202 

treatment,  206 
Active  hyperemia,  43 
Actual  cautery,  422 


Acupuncture  in  aneurysm,  916 
Adams's  osteotomy  of  femur,  376 

saw,  377 
Adenie,  935 
Adenitis,  acute,  933 
treatment  of,  933 
chronic,  933 
tubercular,  934 
treatment,  934 
Adenomata,  491 
sebaceous,  496 
Adhesive  plaster,  420 
Adrenal  tumors,  487 
Aerobic  bacteria,  18 
After-fever,  142 
Agar-agar,  23 

Age,  influence  on  repair,  no 
Air-embolism,  898 
Albuminous  periostitis,  675 
Albuminuric  gangrene,  223 
Albumoses  in  aseptic  wound  fever,  142 
Alcohol  in  aseptic  surgery,  278 

method  of  sterilizing  catgut,  282 
Allis's  classification  of  hip-dislocations,  662 
method  of  reducing  hip-dislocations,  671 
Alveolar  sarcoma,  484 

Ambulatory  dressings  for  fractures  of  leg,  595 
American  bandage  of  foot,  413 
Amceba  coli  in  suppuration,  58 
Amputating  knife,  339 
Amputations,  335 
arm,  345 

scapula  and  part  of  clavicle,  347 
Wyeth's,  345 
Berger's,  347 
Chopart's,  350 
circular  method,  339 
control  of  hemorrhage  in,  337 
elbow-joint,  344 
anterior  flap,  344 
lateral  flap,  345 
fingers,  341 
flap-method,  339 
forearm,  343 
Hey's,  349 
hip-joint,  360 

anterior  flap-method,  362 

racket  method,  361 
circular  method,  353 
Esmarch's  method,  363 
external  racket  incision,  361 
Furneaux-Jordan's  method,  362 
modified  oval  method,  361 
oval  method,  361 
Senn's  bloodless  method,  363 
Wyeth's  bloodless  method,  363 
in  compound  fracture,  518 
in  contiguity,  335 
in  continuity,  335 
instruments  required  in,  339 
intermediate,  335 
interscapulothoracic,  347 

937 


938 


INDEX. 


Amputations,  knee,  357 

Garden's  method,  358 

Gritti's  method,  358 

through  the  condyle,  358 
leg,  354 

Bell's,  356 

Hey-Lee,  355 

lower  third,  354,  357 

middle  third,  355 

upper  third,  356 
Lisfranc's,  349 
long  anterior  flap-method,  340 

rectangular  flap-method,  340 
Malgaigne's,  342 
mediotarsal,  350 
metacarpal  bones,  341 
metacarpophalangeal  articulation,  341 
metatarsal  bone,  349 
methods  of,  339 
oval  method,  340 
Pirogoff's,  352 
preparation  for,  338 
primary,  335 
racket,  341 
Roux's,  352 
secondary,  335 
shoulder-joint,  346 

double-flap  method,  346 

Larrey's  method,  346 

Lisfranc's  method,  346 

oval  method,  346 

Spence's  method,  347 

Wyeth's,  347 
by  skin-flaps  and  circular  division  of  muscles, 

339 
sus  malleolaire,  355 
Symes's,  351 
thigh,  358 

long  anterior  flap-method,  360 
modified  circular  method,  360 

flap-operation  in  lower  third,  359 
Sedillot's  method,  360 
Vermale's,  359 
Wyeth's,  360 
tibiotarsal,  351 
toes,  348 

two  adjoining,  349 
wrist,  342 

anteroposterior  flaps,  342 
circular  method,  342 
external  lateral  flap,  343 
Anaerobic  bacteria,  18 

cultivation,  25 
Anatomical  tubercle,  108,  250 
Anemia,  splenic,  925 
Anesthesia  by  cold,  428 
cocain,  454 

in  minor  surgery,  429 
ethyl  bromid,  in  minor  surgery,  427 

chlorid,  454 
eucain,  455 

in  minor  surgery,  432 
general,  443 
holocain,  453 
infiltration,  455 

in  minor  surgery,  431 
local,  453 

in  minor  surgery,  428 
nitrous  oxid,  457 
and  ether,  460 
and  oxygen,  438 
primary,  453 

in  minor  surgery,  428 


Anesthesia,  spinal,  456 

surgical,  439 
Anesthetic  mixtures,  444 
Anesthetics,  absorption  by  the  blood,  441 

action  on  nervous  system,  442 

death  under,  451 

in  minor  surgery,  427 

influence  in  heart-muscle,  442 

pharmacology  of,  439 

postnarcotic  changes  produced  by,  443 
Aneurysm,  913 

acupuncture  for,  916 

arteriovenous,  914 

axillary,  921 

carotid,  921 

diffuse,  914 

dissecting,  914 

erosion  of  vertebrae  by,  854 

etiology,  915 

false,  914 

femoral,  919 

fusiform,  914 

galvanopuncture  in,  917 

hernial,  914 

innominate,  920 

intracranial,  820 

ligature  in,  918 

needling  for,  917 

of  abdominal  aorta,  919 

of  aorta,  919 

of  iliac  arteries,  919 

of  scalp,  789 

popliteal,  919 

prognosis,  916 

sacculated,  914 

subclavian,  921 

traumatic,  900,  914 

treatment,  916 

true,  914 

tubular,  914 

within  the  head,  820 
Angioleucitis,  928 
Angiomata,  479,  911 

cavernous,  911 

plexiform,  479 
Angular  curvature  in  Pott's  disease,  843 
Anilin-wrater  mixture,  27 

Ankle,  dislocation  of,  651.     See  also  Foot,  dis- 
location of. 

joint,  arthritis  of,  744 
excision  of,  372 
synovitis  of,  743 
Ankylosed  elbow,  excision  of,  367 
Ankylosis  of  hip-joint,  osteotomy  for,  376 

of  jaw,  resection  for,  389 

of  knee-joint,  osteotomy  for,  379 
Anodynes  in  inflammation,  56 
Anterior  crural  nerve,  injury  of,  891 
Anthrax,  194 

bacillus  of,  37 

bacteriology,  37 

course  of,  196 

diagnosis,  197 

etiology,  195 

history,  194 

of  scalp,  78/9 

pathological  anatomy,  196 

prognosis,  198 

symptoms,  196 

treatment,  198 
Antibacillary    injections   in    joint-tuberculosis, 

717 
Antipyretics  in  inflammation,  56 


INDEX. 


939 


Antisepsis,  270 

Antiseptics,  chemical,  275 

Antistreptococcic  serum  in  poisoned  wounds, 

108 
Antitetanin,  187 
Antitoxic  proteids,  42 
Antitoxin,  tetanus,  187 
Antivenene,  211 
Antivenomous  serum,  211 
Aorta,  abdominal,  aneurysm  of,  919 
ligature  of,  327 
aneurysm  of,  919 
Appendicitis,  leukocytosis  in,  83 
Area  of  smell,  795 
of  taste,  79s 
sensorimotor,  793 
sound, 795 
speech,  794 
visual,  794 
Aristol,  279 

Arm,  amputation  of,  339 
Arnott's  plan  of  anesthesia,  428 
Arrest  of  bleeding,  315 
Arterial  hematoma,  900 
hemorrhage,  897 
varix,  911 
Arteries,  ligature  of,  316 
abdominal  aorta,  327 
carotid,  common,  325 
external,  325 
internal,  325 
dorsalis  pedis,  332 
facial,  327 
femoral,  330 

in  Hunter's  canal,  331 
gluteal,  330 
iliac,  common,  327 

extraperitoneal,  328,  330 
external,  328 
internal,  328 
innominate,  317 
lingual,  326 
occipital,  327 
popliteal,  331 
pudic,  internal,  330 
radial,  323 

lower  third,  323 
upper  third,  323 
sciatic,  330 
subclavian,  318 

in  first  portion,  318 
in  second  portion,  318 
in  third  portion,  319 
temporal,  327 
thyroid,  inferior,  320 

superior,  319 
tibial,  anterior,  332 

posterior,  333 
ulnar,  324 
vertebral,  321 
repair  of,  135,  901 
wounds  of,  899 
Arteriosclerotic  gangrene,  222 
Arteriovenous  aneurysm,  900 
Arteritis,  902 
acute,  902 
chronic,  903 
deformans,  903 

obliterans,  gangrene  from,  225 
rheumatic,  903 
suppurative,  903 
symptoms,  904 
syphilitic,  903 


Arteritis,  traumatic,  903 

treatment,  904 
Artery,  axillary,  321 
brachial,  322 

constriction  of,  repair  of,  136 
inflammation  of,  902.     See  also  Arteritis. 
rupture  of,  899 

treatment,  900 
suture  of,  899 
wound  of,  healing  of,  136 
Artery-forceps,  312 
Arthrectomy,  375 
Arthritis,  704 
acute  gouty,  706 
etiology,  706 
treatment,  706 
rheumatic,  707 
diagnosis,  707 
etiology,  707 
symptoms,  707 
treatment,  707 
after  fracture,  522 
deformans,  709 
diagnosis,  705 
etiology,  704 
gonorrheal,  712 
diagnosis,  712 
etiology,  712 
symptoms,  712 
synonyms,  712 
treatment,  712 
neuropathic,  720 
etiology  of,  720 
treatment,  720 
of  ankle,  744 
of  elbow,  746 
of  knee,  739 
of  shoulder,  745 
pathology,  705 
prognosis,  706 
rheumatoid,  709 
diagnosis,  711 
etiology,  710 
pathology,  709 
prognosis,  711 
symptoms,  710 
treatment,  711 
sicca,  709 
strumous,  713 
symptoms,  704 
treatment,  706 
tubercular  osteitic,  713 
amputation  in,  720 
antibacillary  injections  in,  717 
antituberculin  injections  in,  718 
arthrotomy  in,  718 
aspiration  in,  718 
chronic  congestive,  treatment,  718 
diagnosis,  716 
erosion  in,  719 
etiology,  714 
excision  of  joint  in,  720 

of  sac  in,  718 
ignipuncture  in,  717 
pathology,  713 
symptoms,  714 
synonyms,  713 
treatment,  716 
trephining  of  bone  in,  717 
Arthropathie  blennorrhagique,  712 
Arthropathy,  spinal,  720 
Arthrotomy  for  joint-tuberculosis,  718 
Asepsis,  270 


940 


INDEX. 


Aseptic  surgery,  technic  of,  269 
postoperative  fever,  blood  in,  86 
wound  fever,  142 
diagnosis,  143 
etiology,  142 
symptoms,  142 
treatment  of,  143 
Asphyxia,  local,  230 

Aspiration  in  tuberculous  pleurisy  and  empy- 
ema, 255 
Astragalus,  dislocation  of,  causation  and  classi- 
fication, 655 
diagnosis,  657 
frequency,  655 
prognosis,  657 
symptoms,  656 
treatment,  657 
excision  of,  395 
fracture  of,  596 
Atheroma,  903 
Atheromatous  cyst,  786 
Atlo-axoid  disease,  symptoms  of,  846 

dislocation,  824 
Atrophy  of  limb  after  fracture,  521 

of  muscle,  771 
Attenuating  proteids,  41 
Auditory  nerve,  lesions  of,  886 

speech-area,  794 
Auto-intoxication,  140 
diagnosis,  141 
treatment,  141 
Autotransfusion  in  burns,  114 
Avulsion  of  gustatory  nerve,  874 
of  inferior  dental  nerve,  874 
of  infra-orbital  nerve,  873 
of  nerve,  873 

of    supra-orbital   and    frontal    branches    of 
ophthalmic  nerve,  874 
Axillary  aneurysm,  921 
artery,  ligature  of,  321 
suture  of,  899 

Bacelli's  treatment  of  tetanus,  188 

Bacilli,  17 

Bacillus  aerogenes  capsulatus,  40 

coli  communis,  32,  58 

of  anthrax,  37 

of  bubonic  plague,  39 

of  glanders,  36 

of  Lustgarten,  34 

of  malignant  edema,  38 

of  rhinoscleroma,  39 

of  syphilis,  34 

of  tetanus,  38 

of  tuberculosis,  34 

channels  of  entrance  into  the  system,  245 
in  suppuration,  58 

pyocyaneus,  31,  58 

pyogenes  fcetidus,  58 

tetani,  183 

typhosus,  32 
Bacteria,  classification  of,  17 

conditions  of  growth  of,  18 

development  of,  17 

food-supply  of,  18 

methods  by  which  they  affect  the  body,  19 
of  cultivation,  21 

staining  of,  26 

structure  of,    17 

variation  in,  21 
Bacteriological  examinations,  procedure  in,  28 
Bacteriology,  17 

of  the  blood,  85 


Bandages,  404 
Barton's,  414 
Borsch's  eye-,  414 
celluloid,  410 
circular,  406 
compound,  407 
crossed,  of  angle  of  jaw,  415 

of  both  eyes,  414 
demi-gauntlet,  411 
Desault's,  418 
elementary  forms  of,  406 
figure-of-8,  406 

of  jaw  and  occiput,  414 
of  thigh  and  pelvis,  416 
four-tailed,  407 
gauntlet,  411 
Gibson's,  414 
glue,  410 

gum-and-chalk,  410 
many-tailed,  407 
oblique,  406 
of  foot,  American,  413 
covering  heel,  413 
French,  413 
not  covering  heel,  413 
spiral,  covering  heel,  413 
of  head,  recurrent,  420 
of  jaw,  crossed  or  oblique,  415 
ot  special  regions,  410 
of  stump,  recurrent,  420 
paraffin,  410 
plaster  of  Paris,  408 
in  fracture,  513 
recurrent,  407 
Ribbail's,  413 
Selva's  thumb,  412 
Seutin's,  410 
silicate  of  soda,  410 
in  fracture,  514 
spica,  406 

of  groin,  416 
of  shoulder,  416 
of  thumb,  412 
spiral,  406 

of  all  the  fingers,  411 

of  palm  or  dorsum  of  hand,  411 

reversed,  406 

of  lower  extremity,  412 
of  upper  extremity,  410 
starch,  410 
T-,  407 
Tait's,  410 
thumb,  412 
Velpeau's,  416 
Bandaging,  404 

general  rules  for,  405 
Barton's  bandage,  414 
Base-ball  pitchers'  arm,  764 
Beard  of  operator,  288 
Bed-sore,  77,  237 
prevention  of,  238 
signs  of,  239 
treatment  of,  239 
Bell's  amputation  of  leg,  356 
Bending  fracture,  506 
Bengue's  apparatus,  429 
Bennett's  gas-  and  ether  inhaler,  461 
Berger's  amputation,  347 
Biceps  of  arm,  rupture  of,  765 
Bichlorid  of  mercury  as  a  disinfectant,  275 
Bigelow's  classification  of  hip-dislocations,  662 

method  of  reducing  hip-dislocations,  669 
Bismarck  brown,  27 


INDEX. 


941 


Bites  of  insects,  212 
of  serpents,  210 
symptoms,  211 
treatment,  211 
Bladder,  sterilization  of,  294 

tuberculosis  of,  264 
Bleeding,  arrest  of,  315 
Blistering,  426 
Blood,  bacteriology  of,  85 
filaria  sanguinis  hominis  in,  86 
surgical  pathology  of,  80 
transmission  of  pus-microbes  by,  148 
Bloodletting  in  inflammation,  52 

local,  433 
Blood-embolism  in  fracture,  520 
Blood-examination  in  accident  cases  with  shock 

or  hemorrhage,  81 
Blood-regeneration  after  operation,  80 
Blood-serum  as  a  culture  medium,  23 

mixture,  Loffler's,  24 
Blood-tumors  of  scalp,  789 
Blood-vessels,  anatomy  of,  896 
diseases  of,  902 
injuries  of,  896 
Blue  pus,  66 
Boil,  67 

treatment  of,  70 
Bones,  chondromata  of,  700 
diseases  of,  675 
excision  of,  364 
exostoses  of,  699 
gummatous  disease  of,  692 
symptoms,  692 
treatment,  692 
hereditary  syphilis  of,  693 
inflammation  of,  675 
limited  deposits  of  tuberculous  material  in, 

686 
malignant  tumors  of,  701 
necrosis  of,  682.     See  also  Necrosis  of  bone. 
phosphorus  necrosis  of,  693 
repair  of,  131 
sarcomata  of,  700 
myeloid,  701 
round-celled,  701 
spindle-celled,  701 
treatment,  701 
syphilis  of,  691 

symptoms,  691 
syphilitic  caries  of,  692 
tuberculous  disease  of,  686 
etiology,  687 
symptoms,  688 
treatment,  688 
with  abscess,  treatment,  690 
with  septic  sinuses,  treatment,  690 
without  abscess,  treatment,  688 
tumors  of,  699 
Bony  tumors,  475 
Boric  acid,  277,  279 
Borsch's  eye-bandage,  414 
Bouillon,  nutrient,  23 
Brachial  artery,  ligature  of,  322 

neuralgia,  operative  treatment  of,  881 
plexus,  injuries  of,  889 
Bradford's  fixation-frame,  730 
Brain,  abscess  of,  812 
treatment,  813 
carcinoma  of,  815 
compression  of,  810 
contusion  and  concussion  of,  796 
cysts  of,  815 
glioma  of,  814 


Brain,  gumma  of,  815 
operation  on,  817 
hemorrhage  in,  806 
laceration  of,  811 
protrusion  of  membranes  of,  819 
sarcoma  of,  814 

-substance,  hemorrhage  into,  809 
tubercle  of,  815 
tumors  of,  813 

expediency  of  operation,  817 
situation  of,  815 
technic  of  operating,  817 
Brain's  method  of  nitrous  oxid  and  ether  anes- 
thesia, 460 
Branchial  dermoids,  500 
Breast,  strapping  of,  421 
Brook's  incision  for  palmar  abscess,  72,  73 
Briin's   operation    for    repair  of    quadrilateral 

defect,  398 
Bubonic  plague,  bacteriology  of,  39 
Bulbous  nerves,  885 
Bunion,  783 
Burns,  in 

constitutional  symptoms  of,  112 

deformities  after,  repair  of,  399 

degrees  of,  in 

inflammatory  conditions  following,  112 

prognosis,  113 

treatment,  113 

X-ray,  114 

prevention  of,  116 
symptoms  of,  115 
treatment  of,  116 
Burow's    operation    for    repair  of    triangular 

defect,  397 
Burrowing  of  pus,  65 

Bursa   between    tendon   of  semimembranosus 
and    inner    head    of    gastrocnemius, 
inflammation  of,  783 
over  tuber  ischii,  inflammation  of,  783 
over  tubercle  of  tibia,  inflammation  of,  781 
prepatellar,  inflammation  of,  781 
subdeltoid,  inflammation  of,  782 
subgluteal,  inflammation  of,  783 
under  ligamentum  patellre,  inflammation  of, 

781 
under  quadriceps  extensor  tendon,  inflam- 
mation of,  782 
Bursae,  503 
diseases  of,  780 
injuries  of,  780 
tuberculosis  of,  259 
Bursitis,  acute,  780 
signs,  780 
treatment,  781 
chronic,  781 
signs,  781 
treatment,  781 

Calcaneum,  excision  of,  394 
Callous  ulcer,  77 
Callus,  definite,  132 

excessive,  133 

after  fracture,  521 

formation  of,  131 

provisional,  132 

reformation  of,  132 

superfluous,  133 
Calomel  in  aseptic  surgery,  279 
Calor,  51 

Cancellous  osteomata,  475 
Cancer,  492 

squamous-celled,  494 


942 


INDEX. 


Cancrum  oris,  235 

treatment  of,  236 
Cantharides,  blistering  by,  426 
Capillary  hemorrhage,  897 
Capsular  arthritis  of  knee,  739 
Capsule  of  hip-joint,  660 
Carbol-fuchsin,  28 
Carbolic  acid  as  a  disinfectant,  276 
in  tetanus,  188 
of  wounds,  97 
Carbol-thionin  blue,  36 
Carbuncle,  68 

of  scalp,  786 

treatment  of,  70 
Carbunculus  contagiosus,  194 
Carcinoma,  492 

of  brain,  815 

of  skull,  792 

of  spinal  column,  855 

sebaceous,  496 
Carden's  amputation  at  the  knee,  358 
Caries  of  spine,  840.     See  Spine,  caries  of, 
Carnochan's  operation  for  excision  of  second 
division  of  trifacial  nerve,  873 
for  excision  of  third  division    of  trifacial 
nerve,  873 
Carotid  aneurysm,  921 

artery,  common,  ligature  of,  325 
external,  ligature  of,  325 
internal,  ligature  of,  325 
Carpal  bones,  fracture  of,  571 
Carpus,  dislocation  of,  640.     See   Wrist,  dislo- 
cation of. 
Cartilage,  repair  of,  133 
Cartilaginous  tumors,  475 
Caseation,  242 
Cataphoresis,  electrical,  429 
Cataplasm,  424 
Catgut,  280 

chromicized,  283 

sterilization  of,  272 
Cautery,  actual,  422 

Paquelin's,  423 
Cavernous  angioma,  911 

lymphangioma,  480 

nevi,  479 
Cells  of  new  formation,  92 
Cellulitis  of  scalp,  785 
Celluloid  bandage,  410 
Cementomes,  476 

Cerebellar  tumors,  symptoms  of,  817 
Cerebral  localization,  792 
Cervical  abscess,  73 

plexus,  injuries  of,  888 

sympathetic,  lesions  of,  892 
Chamberland  filter,  21 
Charbon, 194 
Charcoal  poultice,  424 
Charcot's  disease  of  joints,  720 
Cheek-bones,  fracture  of,  527 
Chemical  antiseptics,  use  of,  305 

disinfection,  275 

sterilization  in  bacteriological  technic,  22 
Chemiotaxis,  19,  59 
Chilblains,  228 

Chin-cup  in  fracture  of  lower  jaw,  530 
Chlorin  water,  277 
Chloroform,  administration  of,  463 

and  ether,  comparative  merits  of,  451 
Chondromata,  475 

of  bone,  700 

treatment  of,  700 

of  spinal  column,  855 


Chondrosarcomata,  486 
Chopart's  amputation,  350 
Chromicized  catgut,  283 
Chyluria,  931 

blood  examination  in,  86 
Cicatricial  keloid,  128 
Cicatrix,  formation  of,  89 

horns,  491 

injuries  and  diseases  of,  127 

muscular,  129 
Circular  amputation,  339 

bandage,  406 
Circumflex  nerve,  injury  of,  889 
Cirsoid  aneurysm,  911 
Clavicle,  dislocation  of,  616 
backward,  616 

causation  and  classification,  616 
forward,  616 
frequency,  616 
upward,  616 

excision  of,  390 

fracture  of,  537 
diagnosis,  539 
treatment,  540 
Cleveland  ligature-carrier,  313 
Closed  fracture,  507 
Clothing  of  operator,  288 
Clover's  nitrous  oxid  and  ether  inhaler,  460 
Club-foot,  759 

diagnosis,  759 

osteotomy  for,  378 

prognosis,  759 

symptoms,  759 

treatment,  759 
adult  cases,  762 
infantile  cases,  760 
three  to  six  years,  761 
Coachman's  bursa,  783 
Coaptation  of  wounds,  99 
Cocain  anesthesia,  454 
in  minor  surgery,  429 

method  of  injecting,  430 
Cocainization  of  spinal  cord,  456 
Coccydynia,  830 
Coccyx,  dislocation  of,  830 
treatment,  830 

excision  of,  393 

fracture  of,  830 
treatment,  830 
Cold,  anesthesia  by,  428 

arrest  of  hemorrhage  by,  96 

in  inflammation,  52 

local  application  of,  426 
Colin's  apparatus  for  intravenous  injection,  435 
Collapse,  118 
Comminuted  fracture,  505 
Common-salt  solution  as  a  disinfectant,  277 
Compact  osteomata,  475 
Complete  fracture,  505 
Complicated  fracture,  507 
Complications  of  fracture,  519 
Composite  odontomes,  476 
Compound  dislocation,  610 

fracture,  507 

treatment  of,  516 
Compresses,  arrest  of  hemorrhage  by,  96 

hot,  424 
Compression  in  inflammation,  53 

of  brain,  810 

of  cord  in  Pott's  disease,  844 
Compression-paraplegia,  848 

treatment,  852 
Concussion  of  brain,  796 


INDEX. 


943 


Concussion  of  brain,  symptoms,  797 
treatment,  798 
of  spine,  832 
symptoms,  833 
treatment,  834 
Congenital  dislocation  of  hip,  751 

sacrococcygeal  tumors,  839 
Congestion,  43 
Conjoined  twins,  839 
Connective-tissue  tumors,  471 
Constitutional  conditions,  influence  on  repair, 
no 
reactions  to  wounds,  140 
Contraction,    Dupuytren's,    of    palmar   fascia, 

776 
Contractures  of  muscle,  772 
Contre  coup,  fracture  by,  800 
Control  of  hemorrhage,  337 
Contused  wounds,  88 

treatment  of,  98 
Contusion  of  brain,  796 
diagnosis,  797 
symptoms,  797 
treatment,  798 
Contusions  of  joints,  397 
treatment,  598 
of  muscles,  763 
prognosis,  763 
signs,  763 
treatment,  763 
of  nerves,  131,  862 
symptoms,  862 
treatment,  863 
of  skin,  repair  of,  125 
of  skull,  790 
treatment  of,  95,  104 
Cord,  408 

Coronoid  process  of  radius,  fracture  of,  559 
Corpora  oryzoidea,  260 
Corrosive  films,  26 
Costal  cartilages,  fracture  of,  534 
Cotyloid  ligament,  660 
Counterirritants,  425 
Counterirritation  in  inflammation,  53 
Cover-glass  preparations  of  bacterial  cultures, 
26 
staining  of,  27 
Craniotabes,  695 
Cravat,  408 
Creolin,  277 

Crepitus  in  fractures,  508 
Croft's  operation  for  repair  of  deformities  after 

burns,  399 
Crossed  bandage  of  angle  of  jaw,  415 

of  both  eyes,  414 
Crural  nerve,  anterior,  injury  of,  891 
Crushing  of  nerve,  866 
Crutch-paralysis,  864 

after  fracture,  522 
Cryptogenic  infection,  151 
Cuboid  bone,  dislocation  of,  658 
Cultivation  of  bacteria,  methods  of,  21 
Cultures,  anaerobic,  25 
Esmarch's  roll-,  24 
filtration  of,  26 
hanging  drop,  26 
plate-,  24 
Cumol  method  of  sterilizing  catgut,  282 
Cuneiform  bones,  dislocation  of,  658 
osteotomy,  376 

for  inveterate  club-foot,  380 
Cupping,  dry,  433 
wet,  434 


Curvature,  angular,  in  Pott's  disease,  843 

of  spine,  lateral,  857.     See  also  Scoliosis. 
Cushing's  operation  for  removal  of  Gasserian 

ganglion,  880 
Cutaneous  gangrene,  235 
symptoms,  235 
treatment,  233 
horns,  787 
Cyst,  atheromatous,  786 
Cystic  hygroma,  933 
Cystomata,  502 

Cyston's  operation  for  flat-foot,  382 
Cysts,  502 

dermoid,  of  scalp,  787 

gland-,  502 

implantation,  499 

lymphatic,  480 

neural,  504 

of  brain,  815 

parasitic,  504 

retention,  502 

sebaceous,  495 

Dacryops,  503 

Dactylitis,  strumous,  687 

Davy's  method  of  controlling  hemorrhage  in 

hip-amputation,  361 
Dead  tissue,  effect  of,  on  the  body,  215 
Decubitus,  77,  237 

prevention  of,  238 

signs,  239 

treatment,  239 
Defensive  proteids,  41,  59 
Definite-callus,  132 
Deformities  after  burns,  Croft's  operation  for, 

399 
plastic  repair  of,  399 
Deformity  in  fractures,  509 
Degeneration,  ischemic,  216 
Delayed  shock,  119 

union  of  fracture,  523 
Delirium  nervosum,  522 

traumatic,  522 

tremens  after  fracture,  522 
Demarcation,  line  of,  215 

suppuration  of,  112 
Demi-gauntlet  bandage,  411 
Denonvillier's  method  of  rhinoplasty,  400 
Dentigerous  cyst,  476 
Depressed  fracture,  506 
Depression  in  fractures,  509 
Dermatol,  279 
Dermoid  cysts  of  scalp,  787 
Dermoids,  497.     See  also  Cysts. 

branchial,  500 

lingual,  499.     See  also  Lingual  cysts. 

ovarian,  500 

rectal,  499 

sequestration,  497 
Desault's  apparatus,  418 
Diabetic  gangrene,  224 
Diapedesis  of  leukocytes,  47 
Diaphoretics  in  inflammation,  56 
Dieffenbach's  method  of  plastic  repair,  397 

of  rhinoplasty,  401 
Diet  in  inflammation,  55 
Diffuse  aneurysm,  914 

lipomata,  473 
Digital  pressure,  arrest  of  hemorrhage  by,  95 
Dilute  alcoholic  solution,  27 
Diplococcus  lanceolatus,  34 

pneumoniae,  bacteriology  of,  34 
Disarticulation  at  knee,  357 


944 


INDEX. 


Disarticulation  of  all  metatarsal  bones,  349 
of  great  tor  al  metatarsophalangeal  joint,  348 
tarsometatarsal,  349 
Discharges,  bacteriological  examination  of,  29 
Diseased  conditions,  influence  on  repair,  no 
I  )iseases  of  bones,  675 
of  bursa;,  7S0 
of  joints,  702 
of  muscles,  770 
Disinfection.      See  also  Sterilization. 

chemical,  275 
Dislocation,  602 
atlo-axoid,  824 
causation  of,  602 

external  violence,  602 
muscular  action,  603 
compound,  610 
conditions  favoring,  603 
age,  603 

anatomical  peculiarities,  603 
occupation,  605 
sex,  605 
diagnosis  of,  607 
from  fracture,  607 
from  pathological  conditions,  607 
occipito-atloid,  824 

of  ankle,  651.     See  also  Foot,  dislocation  of. 
of  astragalus,  655.     See  also  Astragalus ,  dis- 
location of. 
of  carpus,  640.     See  also    Wrist,  dislocation 

of. 
of  clavicle,  616.     See  also   Clavicle,  disloca- 
tion of. 
of  coccyx,  830 
of  cuboid,  658 
of  cuneiform  bones,  658 
of  elbow,  630 

backward,  operative  reduction  of,  367 
of  fibula,  649 

of  foot,  651.     See  also  Foot,  dislocation  of. 
of  hip,  659.     See  also  Hip,  dislocation  of. 
congenital,  751.     See  also  Hip,  dislocation 
of,  congenital. 
of  humerus,  619.     See  also  Humerus,  dislo- 
cation of. 
of  interphalangeal  joints,  643 
of  ringers,  645 
of  toes,  658 
of  lower  jaw,  613 
of  metacarpophalangeal  joints,  643 

of  fingers,  645 
of  metacarpus,  642 
of  metatarsophalangeal  joints,  658 
of  metatarsus,  658 
of  nerves,  866 
of  os  calcis,  657 
of  os  magnum,  641 
of  patella,  649.     See  also  Patella,  dislocation 

of- 
of  pisiform  bone,  641 
of  radius,  637.     See  also  Radius,  dislocation 

of- 

of  radius  and   ulna,  630.     See  also   Elbow- 
joint,  dislocation  of. 

of  scaphoid  bone,  641,  658 

of  scapula,  617.     See  also  Scapula,  disloca- 
tion of. 

of  semilunar  bone,  641 
cartilage,  723 

of  shoulder-joint,  619.     See   also   Humerus, 
dislocation  of. 

of  spine,  823 

of  tendons,  768 


Dislocation  of  thumb,  643.     See  also    Thumb, 
dislot  at/on  of. 
of  tibia,  646.     See  also    Tibia,  dislocation  of. 
of  ulna,  635 

of  wrist,  640.     See  also  [I  rist,  dislocation  of. 
old,  611 

of  humerus,  629 
treatment,  612 
pathological,  613 
pathology  of,  605 
prognosis,  608 
reduction,  609 
ob  tacles  to,  609 
signs,  609 

and  symptoms  of,  607 
treatment  of,  609 
X-rays  in,  608 
Displacements  of  spleen,  924 

treatment,  924 
Dissecting  aneurysm,  914 
Dissection,  technic  of,  315 
Diverticula,  503 
Dolor,  51 

Dorsal  abscess  in  Pott's  disease,  847 
treatment,  851 
dislocation  of  hip,  662,  663.     See  also  Hip, 
dislocation  of. 
of  spine.  824 
Dorsalis  pedis,  ligation  of,  332 
Drainage  by  rib-resection,  256 

in  tuberculous  pleurisy  and  empyema,  255 
of  accident  wounds,  296 
of  operation  wounds,  297 
of  wounds,  100 
Drainage-tubes,  298 
Dressing  of  wounds,  102 
Dressings,  284 
change  of,  304 
fixed,  408 
revision  of,  103 
sterilization  of,  285 
Dry  cupping,  433 
gangrene,  214 

heat,  local  application  of,  422 
hot  air,  cauterization  by,  422 
Dubrueil's  amputation  at  the  wrist,  343 
Dunham's  peptone  solution,  24 
Dupuytren's  contraction  of  palmar  fascia,  776 

ECCHONDROSES,  475 

Ecchymosis  in  fractures,  510 
Edema,  malignant,  197 
Elbow-joint,  amputation  at,  344 
arthritis  of,  746 
diseases  of,  745 
dislocation  of,  630 

causation  and  classification,  630 

compound,  635 

diagnosis,  633 

divergent,  631,  633 

old,  635 

pathology,  631 

symptoms,  631 

treatment,  634 

unreduced  backward,  operative  reduction 

of,  367 

excision  of,  366.    See  Excision  of  elbow-joint. 

rheumatism  of,  748 

sprain  of,  745 
Electrical  cataphoresis,  429 
Elephantiasis,  930 

false,  930 
Elliptical  defects,  plastic  repair  of,  398 


INDEX. 


945 


Elliptical  defects,  repair  by  Weber's  operation, 

398 
Embolism,  908 

air-,  898 

fat-,  123.     See  Fat-embolism. 

symptoms,  909 

treatment,  909 
Emphysema  after  fracture,  522 
Emphysematous  gangrene,  233 
Empyema,  tuberculous,  255 
Encephalocele,  790 
Endarteritis  obliterans,  903 
Enema,  how  to  give,  438 

nutritive,  injection  of,  438 
Enlargement,  chronic,  of  spleen,  924 
Enostoses  of  skull,  791 
Environment,  influence  of,  on  tumors,  466 
Eosin,  27 

Epididymis,  tuberculosis  of,  263 
Epididymitis,  tubercular,  263 
Epilepsy,  trephining  for,  821 
Epiphysitis,  acute,  677 
diagnosis,  678 
treatment,  680 

with  suppuration  in  neighboring  joints,  681 
Epithelial  odontomes,  476 

pearls,  494 

tumors,  489 
Epithelioid  cells  of  tubercle,  244 
Epithelioma  of  scalp,  789 
Erasion  of  a  joint,  375 
Erethistic  shock,  treatment,  122 

ulcer,  77 
Ergotism,  gangrene  from,  229 

in  joint-tuberculosis,  719 
Erysipelas,  173 

ambulans,  175 

curative  influence  of,  179 

etiology,  173 

facial,  176 

habitual,  175 

metastatic,  175 

migrans,  175 

neonatorum,  177 

of  scalp,  785 

pathological  anatomy,  177 

phlegmonous,  176 

prognosis,  178 

symptoms,  174 

traumatic,  126 

treatment,  178 

varieties,  176 

wandering,  175 
Esmarch's  amputation  at  hip-joint,  363 

roll-cultures,  24 
Estlander's  resection  of  ribs,  389 
Ether  and  chloroform,  comparative  merits  of,45 1 

as  an  anesthetic,  444 

in  aseptic  surgery,  278 

mode  of  administration,  445 

precautions  to  be  taken  before  giving,  445 
Etherization,  446 

complications  in,  449 

rectal,  448 
Ethyl  bromid,  anesthesia  from,  444 
in  minor  surgery,  427 

chlorid,  454 

in  local  anesthesia,  429 
Eucain,  455 

anesthesia  in  minor  surgery,  432 
Europhen,    279 
Excessive  callus,  133 
Excision  of  ankle-joint,  372 

60 


Excision  of  ankle-joint,  Lauenstein's,  373 
of  ankylosed  elbow,  367 
of  astragalus,  395 
of  bones  and  joints,  364 
of  calcaneum,  394 

Faraboeuf's  method,  394 
of  clavicle,  390 
of  coccyx,  393 
of  elbow-joint,  366 
ankylosed,  367 
Ollier's  method,  367 
Von  Langenbeck's,  366 
of  Gasserian  ganglion,  878 
of  hip-joint,  370 

anterior  incision,  371 
Ollier's,  371 

Von  Langenbeck's,  370 
of  humerus,  391 
of  inferior  maxilla,  387 
anterior  portion,  388 
lateral  portion,  388 
ramus  and  half  of  the  body,  388 
of  joints  and  bones,  364 
of  knee-joints,  372 

in  knee-joint  disease,  742 
semilunar  incision,  372 
of  metacarpal  bones,  392 
of  metatarsal  bones,  395 
of  phalanges,  392,  395 
of  radius,  392 
of  scapula,  390 
of  shoulder-joint,  364 
Hueter's  incision,  365 
Xelaton's,  366 
Ollier's  method,  365 
transverse  incision,  366 
Von  Langenbeck's  method,  364 
of  superior  maxilla,  384 

above  alveolar  process,  386 
by  median  incision,  384 
Guerin's  operations,  386 
Ollier's,  385 
subperiosteal,  385 
of  ulna,  391 
of  wrist,  368 

bilateral  incision,  368 
dorsoradial  incision,  370 
Von  Langenbeck's,  370 
Excisions,  general  principles  governing,  364 
Exophthalmic    goiter,     resection    of    cervical 

sympathetic  for,  892 
Exostoses,  476,  699 
ivory,  699 
of  skull,  791 
treatment  of,  699 
Extension  in  fracture,  515 
Extra-articular  fracture,  507 
Exudation,  47 
Eye-bandage,  Borsch's,  414 

figure-of-8,  414 
Eyelids,  sterilization  of,  294 
Eyes,  crossed  bandage  of  both,  414 

FACIAL  artery,  ligature  of,  327 

erysipelas,  176 

nerve,  lesions  of,  886 

paralysis,  886 
treatment,  886 
False  aneurysm,  914 

elephantiasis,  930 

point  of  motion  in  fractures,  508 
Faraboeuf's  amputation  of  the  leg,  357 

excision  of  calcaneum,  394 


946 


INDEX. 


Farcin,  198 

Farcy,  198.     See  also  Glanders. 
Fat-embolism,  123 
diagnosis,  124 

in  fracture,  520 
prognosis,  124 
symptoms,  123 
treatment,  125 
Fatty  tumors,  473 
of  scalp,  788 
Faulty  union  of  fracture,  523 
Felon,  72,  773 
symptoms,  774 
treatment,  774 
Femoral  aneurysm,  919 
arterj ,  ligature  of,  330 
common,  ligature  of,  330 
superficial,  ligature  of,  331 
Femur,  fracture  of,  573 
lower  third  of,  583 
neck  of,  573 
diagnosis,  576 
prognosis,  576 
symptoms,  575 
treatment,  577 
shaft  of,  578 
diagnosis,  579 
prognosis,  579 
treatment,  580 
through  upper  third  of  shaft  of,  583 
upper  extremity  of,  573 
osteotomy  of,  for  ankylosis  of  hip,  376 

for  genu  valgum,  378 
relation  of,  to  hamstring  muscles  and  sciatic 

nerve,  661 
resection  of,  393 
Ferment  fever,  142 
Fermented  poultice,  424 
Fetus,  acardiac,  501 

parasitic,  501 
Fever,  aseptic  wound,  142 

in  fractures,  510 
Fibroid,  uterine,  481 
Fibroma  of  nerve,  883 
of  scalp,  788 
simple,  476 
Fibromata,  476 
Fibrous  odontomes,  476 
union  of  fracture,  524 
Fibula,  dislocation  of,  649 

causation  and  classification,  649 
pathology,  650 
prognosis,  650 
symptoms,  649,  650 
treatment,  649,  650 
fracture  of,  590 
resection  of,  393 
Fifth  nerve,  excision  of  second  and  third  divi- 
sions of,  876 
second  division  of,  875 
third  division  of,  875 
neurectomy  of,  875 
Figure-of-8  bandage,  406 
of  both  eyes,  414 
of  jaw  and  occiput,  414 
of  thigh  and  pelvis,  416 
Filaria,  929 

sanguinis  hominis  in  the  blood,  86 
Fillebrown  ether  apparatus,  465 
Filtration  of  bacteria,  21 

of  cultures,  26 
Finger,  snap-,  779 
trigger-,  779 


Fingers,  amputation  of,  341 

dislocation  of  interphalangeal  joints  of,  645 

of  metacarpophalangeal  joints  of,  645 
spiral  bandage  of,  41 1 
First  intention,  healing  b\ ,  91 
Fissure  of  Rolando,  location  of,  796 

■  if  Sj  Ivius,  location  of,  796 
Fissured  fracture,  506 
Fistula,  78 
in  ano,  79 
treatment  of,  79 
Fixation-pins   for   displacement  of  nasal   sep- 
tum, 527 
Fixed  dressing--,  408 
Flagella,  staining  of,  28 
Flaps,  amputation,  336 
Flat-foot,  756 
diagnosis,  757 
etiology,  757 
osteotomy  for,  381 
symptoms,  757 
treatment,  757 
Flaxseed  poultice,  424 
Follicular  odontomes,  476 
Fomentations,  hot,  424 
Foot,  American  bandage  of,  413 
dislocation  of,  651 
sagittal,  651 
causation,  651 
diagnosis,  652 
frequency,  651 
pathology,  651 
prognosis,  652 
symptoms,  651 
treatment,  652 
subastragaloid,  652 
causation,  653 
diagnosis,  654 
frequency,  653 
prognosis,  654 
treatment,  654 
the  astragalus,  655.     See  Astragalus,  dis- 
location of. 
French  bandage  of,  413 
fractures  of,  596 
Ribbail's  bandage  of,  413 
spiral  bandage  of,  413 
Foot-bath,  mustard,  425 
Foot-bones,  excision  of,  394 
Forceps,  312 

arrest  of  hemorrhage  by,  96 
Forearm,  amputation  of,  343 
fracture  of  bones  of,  556 
along  their  shaft,  560 
Foreign  material  in  wounds,  removal  of,  98 
Four-tailed  bandage,  407 
Fourth  nerve,  lesions  of,  886 
Fractures,  505 
bending,  506 
blood-pathology  in,  86 
bv  contre  coup,  507,  800 
by  direct  force,  507 
bv  indirect  force,  507 
by  muscular  contraction,  507 
closed,  507 
comminuted,  505 
complete,  505 
complicated,  507 
complications,  519 
compound,  507 

treatment  of,  516 
delayed  union  of,  523 
depressed,  506 


INDEX. 


947 


Fractures,  diagnosis,  510 
etiology,  507 
extra-articular,  507 
faulty  union  of,  523 
fibrous  union  of,  524 
fissured,  506 
for  arrachement,  606 
gunshot,  505 
impacted,  506 
incomplete,  505 
intra-articular,  506 
intracapsular,  506 
intra-uterine,  525 
ligamentous  union  of,  524 
mixed,  507 
multiple,  505,  507 
non-union  of,  524 
of  acetabulum,  573 
of  astragalus,  596 
of  bones  of  foot,  596 
of  bones  of  forearm,  556 

along  their  shafts,  560 
of  bones  of  leg,  590 
of  carpal  bones,  571 
of  clavicle,  537 
of  coccyx,  830 

of  coronoid  process  of  radius,  559 
of  costal  cartilages,  534 

of  cranium,  787.    See  also  Skull,  fracture  of. 
of  femur,  573 
of  fibula,  590 
of  humerus,  544 

at  surgical  neck  with  displacement,  548 
external  condyle  of,  553 
head  of,  545 
internal  condyle  of,  552 
lower  extremity  of,  551 
shaft  of,  548 

sUpracondyloid,  551,  553 
through  surgical  neck,  544 
of  hyoid  bone,  533 
of  laminae  of  vertebra,  825 
of  lower  jaw,  529 
of  malar  bone,  527 
of  metacarpal  bones,  572 
of  metatarsal  bones,  596 
of  nasal  bones,  525 

process  of  superior  maxilla,  525 
of  neural  arch,  825 
of  nose,  525 
of  olecranon,  556 
of  patella,  586 
of  pelvis,  572 
of  phalanges,  572 

of  toes,  596 
of  pubic  bone,  572 
of  radius,  coronoid  process,  559 
head  of,  559 
lower  extremity  of,  563 
shaft  of,  562 
of  ribs,  534 
of  scapula,  542 

of  skull,  800.     See  also  Skull,  fracture  of. 
of  spine,  825 
of  spinous  process,  825 
of  sternum,  533 

of  superior  maxillary  bone,  527 
of  tibia,  590 
of  ulna,  shaft  of,  562 
of  vault  of  cranium,  799 
of  wrist  bones,  571 
open, 507 
pathological,  507 


Fractures,  penetrating,  505 

plaster  bandage  in,  513 

Potts,  593 

punctured,  505 

reduction  of,  512 

silicate  of  soda  bandage  in,  514 

simple,  507 

splints  for,  513 

spontaneous,  507 

stellate,  505 

symptoms  of,  508 

traumatic,  507 

treatment,  511 

ununited,  resection  of  bones  for,  382 
wiring  of,  383 

varieties  of,  505 

vicious  union  of,  523 

with  angular  displacement,  506 

with  longitudinal  displacement,  506 

with   overriding,  506 

with  rotary  displacement,  506 

with  transverse  displacement,  506 
Fracture-dislocation  of  spine,  825 
Frankel's  pneumococcus,  34 
Freezing,  anesthesia  by,  429 
French  bandage  of  foot,  413 
Frost-bite,  228 

treatment  of,  228 
Fuchsin,  27 
Functio  laesa,  51 

Functional  disorders  of  muscle,  772 
Fungating  wens,  496 
Fungous  ulcer.  77 
Fiirbringer's  method  of  sterilizing  operator's 

hands,  289 
Furneaux-Jordan's  amputation  at  the  hip-joint, 

362 
Furor,  190 
Furuncle,  67 
Furuneulosis,  68 
Fusiform  aneurysm,  914 

Gabbat's  method  of  staining  tubercle  bacilli, 

35 
Galvanocautery,  423 
Galvanopuncture  in  aneurysm,  917 
Ganglion,  775 

treatment,  776 
Ganglionic  neuromata,  478 
Gangrene,  213 
albuminuric,  222 
arteriosclerotic,  222 
classification  of,  213 
cutaneous,  235 
symptoms,  235 
treatment,  235 
diabetic,  222 
dry,  214 

effect  of,  on  the  body,  215 
emphysematous,  233 
from  arteritis  obliterans,  225 
from  cold,  228 
from  ergotism,  229 

treatment,  229 
from  frost-bite,  228 

from  impairment  of  the  general  circulation, 
216 
treatment,  217 
from  lead,  230 

from  obstruction  of  abdominal  aorta,  219 
symptoms  of,  219 
treatment  of,  220 
of  axillarv  and  brachial  vessels,  222 


94& 


INDEX. 


Gangrene  from  obstruction  of  capillaries  and 
small  veins,  231 
of  femoral  artery  and  vein,  221 
of  main  artery  or  vein,  217 
of  the  smaller  arteries,  222 
symptoms,  223 
treatment,  223 
of    superficial   femoral    and    the  popliteal 
arteries  and  veins,  221 
from  spasm  of  the  arterioles,  227 
hospital,  179 
diagnosis,  181 
forms  of,  180 
prognosis,  182 
treatment,  182 
inflammatory,  233 
moist,  214 
of  scalp,  78b 
of  umbilicus,  235 
treatment,  236 
Raynaud's,  230 
symptoms,  231 
treatment,  231 
senile,  222 
septic,  233 
simple  traumatic,  232 

treatment,  232 
spreading  traumatic,  234 
symptoms,  234 
treatment,  235 
Gant's  osteotomy  of  femur,  377 
Gasserian  ganglion,  excision  of,  878 
Krause-Hartley  method,  879 
Rose's  method,  879 
Gastric   juice,  extraction,  of,  for   examination, 

437 
Gauntlet  bandage,  411 
Gauze,  285 

iodoform,  285 
Gelatin,  nutrient,  22 
General  anesthesia,  443 
Genitocrural  nerve,  neurectomy  of,  891 
Genito-urinary  organs,  tuberculosis  of,  261 
Gentian  violet,  27 
Genu  valgum,  osteotomy  for,  378 
Germicidal  proteids,  41 

Gerster's    excision   of  second    division   of    tri- 
facial, 875 
Giant  cells  of  tubercle,  242 
Gibson's  bandage,  414 
Gigli's    method  of  applying  plaster   bandage, 

408 
Girdle-pain,  845 
Gland-cysts,  502 
(danders,  198 

bacillus,  36 

bacteriology  of,  36 

course,  199 

diagnosis,  200 

morbid  anatomy,  199 

symptoms,  199 
in  horses,  198 

treatment,  200 
Glands,  repair  of,  139 
Gliomata,  477 

of  brain,  814 
Glossopharyngeal  nerve,  lesions  of,  887 
Gloves,  operating,  291 
"  Glucose  media,  23 
Glue  bandage,  410 
Gluteal  abscess  in  Pott's  disease,  847 

artery,  ligature  of,  330 
Gonocele,  712 


Gonococci  in  septicemia,  150 
GonocoCCUS,  bacteriology  of,  33 
( ionorrheal  arthritis,  712 

1  heumatism,  712 
of  wrist,  748 
( iouty  arthritis,  acute,  706 
Grafting,  tendon-,  769 
Gram's  method  of  staining,  28 

mixture,  28 
<  iranulation,  stage  of,  91 
Granulation-tissue,  48 
Granulations,  65,  90 

as  a  protection  against  bacteria,  149 
Great    toes,   disarticulation    of,   at    metatarso- 
phalangeal joint,  348 
Green-stick  fracture,  506 
(jritti's  amputation  at  knee,  358 
Groin,  spica  bandage  of,  416 
Guerin's  excision  of  superior  maxilla,  386 
Gum-and-chalk  bandage,  410 
Gumma  of  brain,  815 
operation  on,  817 

of  skull,  791 
Gummata,  scrofulous,  250 
Gummatous  disease  of  bone,  692 
Gunpowder  grains,  removal  of,  98 
Gunshot  fracture,  505 

wounds  of  head,  805 
Gunstock  deformity,  552,  553 
Gustatory  nerve,  avulsion  of,  874 
Guyon's  amputation  of  leg,  355 

Habitual  erysipelas,  175 

Hadern-Krankheit,  194 

Hair  of  operator,  288 

Hairy  mole,  479 

Hallux  valgus,  osteotomy  for,  380 

Hammer-toe,  777 

treatment,  778 
Hamstring  muscles,  relation  of,  to  hip-disloca- 
tion, 661 
Hand,  fracture  of  bones  of,  572 
Handkerchief  dressings,  Mayor's,  407 
Hands  of  operator,  preparation  of,  for  opera- 
tion, 288 
sterilization,  of,  288 
Hanging-drop  cultures,  26 
Hard  palate,  resection   of,  for  nasopharyngeal 

polyps,  386 
Hardening  of  tissues  for  bacteriological  exam- 
ination, 26 
Head,  gunshot  wounds  of,  805 

recurrent  bandage  of,  420 

teratoma  of,  788 
Head-tetanus,  185 
Healing  by  first  intention,  91 

by  second  intention,  91 

influences  affecting,  109 

of  arteries,  135 

of  bone, 131 

of  cartilage,  133 

of  glands,  139 

of  muscle,  129 

of  nerve,  130 

of  skin,  125 

of  special  tissues,  125 

of  tendon, 128 

of  wounds,  histology  of,  91 

origin  of  connective-tissue  cells  in,  94 

under  the  scab,  126 

Heart,  wounds  of,  894 

symptoms,  894 

treatment,  894 


IXDEX. 


949 


Heat,  arrest  of  hemorrhage  by,  96 
as  a  symptom  of  inflammation,  51 

dry,  local  application  of,  422 
in  inflammation,  52 
in  sterilization,  272 
local  application  of,  422 
moist,  application  of,  423 
Heat-sterilization  in  bacteriological  technic,  21 
Heberden's  nodes,  711 
Hematoma,  arterial,  900 
of  scalp,  786 
venous,  900 
Hematomyelia,  traumatic.  831 
prognosis,  832 
symptoms,  832 
treatment,  832 
Hematorachis,  83c 
prognosis,  831 
symptoms,  831 
treatment,  831 
Hemophilia,  87 
etiology,  87 
prognosis,  87 
symptoms,  87 
treatment.  87 
Hemorrhage,  896 
arrest  of,  95 

by  chemical  means,  96 
by  cold,  96 
by  compresses,  96 
by  digital  pressure,  95 
by  forceps,  96 
by  heat,  96 
arterial,  897 

blood-examination  in,  81 
brain,  806 
capillary,  897 
control  of,  897 
extradural,  806,  807 
from  wounds,  89 

arrest  of,  95 
into  brain-substance,  809 
into  lateral  ventricle,  809 
intracranial,  806 
treatment,  808 
methods  of  controlling,  337 
secondary,  898 

spinal    meningeal,    830.      See   also  Hemato- 
rachis. 
subduial,  806,  807 
venous,  897 
Hemorrhagic  ulcer,  77 
Hereditary  syphilis  of  bone,  693 
Hernia  cerebri,  809 

of  muscle,  764 
Hernial  aneurysm,  914 
Hewitt's  apparatus,  428 

nitrous-oxid  apparatus,  457 

and  oxygen  apparatus,  459 
Hey-Lee  amputation  of  leg,  355 
Hey's  amputation,  349 
Hip,  dislocation  of,  after-treatment,  672 
classification,  662 
complications,  672 

cleaning  out  the  socket,  672 
entanglement  of  sciatic  nerve,  673 
fracture  of  shaft,  673 
compound,  674 
congenital,  751 
diagnosis,  751 
pathological  anatomy,  751 
prognosis,  752 
treatment,  752 


Hip,   dislocation     of,     congenital,     treatment, 
gradual    reduction    by    mechanical 
appliances,  756 
neo-arthrosis  operation,  756 
reduction  after  incision,  752 
reduction    by    forcible    manipulation, 
754 
varieties,  751 
dorsal,  662,  663 

signs,  667 
mechanism,  663 
pathology,  664 
reduction,  669 

Allis's  method,  671 
Bigelow's  method,  669 
signs,  667 
thyroid,  662,  663 
signs,  668 
Hip-joint,  amputation  at,  360 
anatomy  of,  659 
disease,  724 
cause,  725 
diagnosis,  729 
symptoms,  725 
treatment  of  abscess  in,  734 
by  excision  of  joint,  735 
osteotomy,  737 
excision  of,  370 

simple  traumatic  inflammation  of,  737 
Hodgkin's  disease,  935 

blood  in,  85 
Holocain,  455 
Horns,  491 
cicatrix,  491 
cutaneous,  787 
nail,  491 
of  scalp,  787 
sebaceous,  491 
wart,  491 
Horsehair,  sterilization  of,  283 
Hospital  gangrene,  179 
diagnosis,  181 
diphtheritic  form  of,  180 
prognosis,  182 
pulpy  form  of,  181 
treatment,  182 
ulcerating  form  of,  180 
Hot  fomentations,  424 
Housemaid's  knee,  781 
Humerus,  dislocation  of,  619 

causation  and  classification  of,  619 
complicated,  628 
compound,  628 
diagnosis,  623 

differential,  624 
frequency,  619 
infraspinous.  symptoms,  623 
old,  629 
pathology,  620 
prognosis,  624 
subclavicular,  pathology,  620 

symptoms,  622 
subcoracoid,  pathology,  620 

symptoms,  621 
subglenoid,  pathology,  620 

symptoms,  622 
subspinous,  pathology,  620 

symptoms,  623 
supracoracoid,  symptoms,  623 
symptoms,  621 
treatment,  625 

by  hyperextension,  628 
Kocher's  method,  626 


95o 


INDEX. 


Humerus,  dislocation  of,  treatment,  pendulum 
method,  628 
excision  and  resection  of,  391 
fracture  of,  544 

at  surgical  neck,  544 
external  condyle  of,  553 
head  of,  545 
diagnosis,  546 
prognosis  of,  547 
treatment,  5  17 
internal  condyle  of,  552 
lower  extremity  of,  551 
diagnosis,  554 
treatment  of,  554 
shaft,  548 

diagnosis,  549 
non-union  of,  550 
prognosis,  549 
treatment,  549 
supracondyloid,  551,  553 
with  displacement,  548 
Hydatid  cyst  of  spinal  column,  855 
Hydrocele  of  neck,  480 
Hydroceles,  502 
Hydrocephalus,  819 

treatment,  820 
Hydrogen  peroxid,  277 
Hydrophobia,  190 

anatomical  findings  in,  191 
diagnosis,  193 
in  dog,  192 
distribution  of,  190 
etiology,  190 
frequency,  190 
history,  190 
prognosis,  193 
symptoms  in  inoculated  animals,  191 

in  man,  192 
treatment  of,  193 
Hygienic  conditions,  influence  on  repair,  109 
Hygroma,  cystic,  933 
Hvoid  bone,  fracture  of,  533 
prognosis,  533 
symptoms,  533 
treatment,  533 
Hyperemia,  43 
active,  43 

from  paralysis  of  the  perivascular  ganglia,  44 
of  irritation,  44 
of  paralysis,  44 
passive,  45 
Hypertrophy  of  muscle,  770 
Hypodermoclysis,  435 

in  septicemia  and  pyemia,  170 
Hypoglossal  nerve,  injury  of,  888 
Hysterical  joint,  721.     See  also  Neuromitnesis. 

Ichor,  66 

Idiopathic  tetanus,  183 

Iliac  abscess  in  Pott's  disease,  847 

arteries,  aneurysm  of,  919 

artery,  common,  ligature  of,  327 
external,  ligature  of,  328 
internal,  ligature  of,  328 
Iliofemoral  ligament,  660 
Iliohypogastric  nerve,  injury  of,  891 
Ilio-inguinal  nerve,  injury  of,  891 
Iliopsoas  abscess  in  Pott's  disease,  847 
Imbecility,  trephining  for,  820 
Immunity  to  pyogenic  infection,  58 
Impacted  fracture,  506 
Implantation  cysts,  499 
Incomplete  fracture,  505 


Indian  method  of  plastic  surgery,  398 

of  rhinoplasty,  401 
India-rubber  gloves,  291 
Infected  wound,  treatment  of,  304 
Infection,  cryptogenic,  151 
immunity  to,  58 
local,  57 

conditions  favorable  for,  59 
spontaneous,  151 
Infective  inflammation,   57 
Inferior  dental  nerve,  avulsion  of,  874 
Infiltration  anesthesia,  455 

Schleich's,  in  minor  surgery,  431 
Inflamed  ulcer,  77 
Inflammation,  45 

constitutional  treatment  of,  54 
infective,  57 
leukocytes  in,  47,  48 
of  artery,  902.     See  also  Arteritis. 
of  bone,  675.     See  also    Osteitis,  Periostitis, 
and   Osteomyelitis. 
acute    suppurative,  675.     See  also    Osteo- 
111  vet  it  is,  acute. 
of  joints.     See  also  Arthritis  and  Synovitis. 
of  muscles,  770 
of  tendon-sheaths,  773.     See  also  Tenosyno- 

vitis. 
pathology,  46 
phlegmonous,  73 
septic,  57 
simple,  45 
symptoms,  50 
treatment,  52 
Inflammatory  conditions  following  burns,  112 
diseases  of  spleen,  924 
gangrene,  233 
Infra-orbital  nerve,  avulsion  of,  874 
Injections,  intramuscular,  436 
of  mercury  for  syphilis,  436 
Injuries  of  blood-vessels,  896 
of  bursse,  780 
of  joints,  597 
of  scalp,  784 
of  skull,  790 
Innocent  tumors,  characters  of,  466 

coexistence  of  two  genera  in  the  same  per- 
son, 470 
I  Innominate  aneurysm,  920 

artery,  exposure  of,  by  resection  of  the  ster- 
num, 318 
ligature  of,  317 
Inoculation  experiments,  29 
Insect-bites,  212 
symptoms,  212 
treatment,  212 
Instrument  table,  310 

arrangement  of,  302 
Instruments,  312 

sterilization  of,  287 
Intercostal  nerves,  neuralgia  of,  890 
Intermuscular  lipomata,  474 
Interphalangeal  joints,  dislocation  of,  643,  658 

of  fingers,  dislocation  of,  645 
Interrupted  plaster  dressing,  409 
Interscapulothoracic  amputation,  347 
Intestinal  tract,  sterilization  of,  294 
Intra-articular  fracture,  506 
Intracapsular  fracture,  506 
Intracranial  aneurysm,  820 
hemorrhage,  806 
treatment,  808 
tumors,  813 
operation  on,  817 


INDEX. 


951 


Intracranial  hemorrhage,  situation  of,  815 

technic  of  operating,  817 
Intracystic  papillomata,  490 
Intramuscular  injections,  436 

lipomata,  474 
Intrauterine  fractures,  525 
Intravenous  injection  of  saline  fluid,  435 
Intussusception,  rectal  inflation  in,  437 
Iodoform,  278 

gauze.  285 

-poisoning,  279 
Ischemic  degeneration,  216 
Ischiofemoral  ligament,  660 
Italian  method  of  plastic  surgery,  398 

of  rhinoplasty,  403 
Ivory  exostoses,  699 

Jaesche's  operation  for   repair  of  triangular 

defect,  397 
Jaundice,  pathology  of  blood  in,  84 
Jaw,  ankylosis  of,  resection  for,  389 
crossed  or  oblique  bandage  of,  415 
dislocation  of,  613 
causation,  613 
diagnosis,  615 
pathology,  614 
prognosis,  614 
symptoms,  614 
treatment,  615 
lower,  dislocation  of,  613 

fracture  of,  530 
upper,    excision   of,    384.     See  Excision   of 
superior  maxilla. 
fracture  of,  527 
Joint,  hysterical,  721.     See  Neuromimesis. 
Joints,  contusions  of,  597 
treatment,  598 
diseases  of,  702 

dislocations  of,  602.     See  Dislocation. 
erasion  of,  375 
excision  of,  364 

inflammation  of.  See  Arthritis  and  Synovitis. 
injuries  to,  597 
loose  bodies  in,  722 
cartilages  of,  475 
special  diseases  of,  724 
sprains  of,  598 
results,  599 
treatment,  599 
suppuration  of,  600 
tuberculosis   of,    713.      See    also   Arthritis, 

tubercular  osteitic. 
wounds  of,  600 
results,  601 
signs,  600 
treatment,  601 
Joint-tuberculosis,    713.      See    also  Arthritis, 
tubercular  osteitic . 

Kangaroo-tendon,  chromicized,  283 

Karyokinesis  in  leukocytes,  49 

Keen's    operation  upon  the    posterior  rotator 

nerves,  882 
Keloid,  cicatricial,  128 

of  scalp,  788 
Kidney,  tuberculosis  of,  266 
Knee,  amputation  at,  357 

dislocation  of,  646.    See  Tibia,  dislocation  of . 
Knee-joint,  ankylosis  of,  osteotomy  for,  376 
arthritis  of,  739 

treatment,  740 
diseases  of,  737 
treatment,  741 


Knee-joint,  diseases  of,  treatment,  excision,  742 

excision  of,  372,  742 

osteoarthritis  of,  740 

synovitis  of,  737 
treatment,  738 

tumor  of,  740 

white  swelling  of,  740 
Knife,  manner  of  holding,  315 
Knot,  reef,  338 

square,  338 
Kny-Sprague  sterilizer,  274 
Koch  syringe,  29,  30 
Kocher's   method  of  reducing  dislocation    of 

humerus,  626 
Koch's  method  of  staining  tubercle  bacilli,  35 
Krause-Hartley  method  of  excising  Gasserian 

ganglion,  879 
Kriebelkrankheit,  229 
Krdnlein's    operation    for    excision    of    third 

division  of  fifth  nerve,  875 
Kiihne's  methylene  blue,  27 

LacERATKD  wounds,  88 
Laceration  of  nerve,  866 
Laminoe  of  vertebra,  fracture  of,  825 
Laminectomy,  834 

Larrey's  amputation  at  shoulder-joint,  346 
Laryngeal  spasm,  888 

Lateral  curvature  of  spine,  857.     See  also  Sco- 
liosis. 
ventricle,  hemorrhage  into,  809 
Lauenstein's  excision  of  ankle-joint,  373 
Lavage  of  stomach,  436 
Lead,  gangrene  from,  228 
Leeches,  433 

Le  Fort's  tibiotarsal  amputation,  354 
Leg,  amputation  of,  354.    See  also  Amputation 
of  leg. 
fracture  of,  590 

ambulatory  dressings  for,  595 
prognosis,  593 
treatment,  593 
Leiter's  apparatus,  424 
Leontiasis,  792 
Leprosy,  bacteriologv  of,  36 
Letenneur's   operation    for   repair   of   quadri- 
lateral defect,  398 
Leukemia,  lymphatic,  935 
pathology  of  blood  in,  85 
splenic,  925 
Leukocytes  in  inflammation,  47,  48 
in  suppuration,  63 
of  tubercle,  245 
Leukocytosis  in  abscess,  81 
in  suppuration,  82 
in  treatment  of  septicemia,  170 
Ligamentous  union  of  fracture,  524 
Ligamentum  patellae,  rupture  of,  767 
Ligature  of  arteries,  316 
abdominal  aorta,  327 
axillary,  321 

in  axilla,  322 
brachial,  322 
carotid,  common,  325 
external,  325 
internal,  325 
dorsalis  pedis,  332 
facial,  327 
femoral,  330 

in  Hunter's  canal,  331 
general  principles,  316 
gluteal,  330 
iliac,  common,  327 


952 


INDEX. 


Ligature  of  arteries,  common  iliac,  extraperi- 
toneal, 328, 330 
external,  328 
internal,  328 
innominate,  317 

by  resection  of  a  portion  of  the  sternum, 
'318 
lingual,  326 
occipital,  327 
popliteal,  331 
pudic,  internal,  330 
radial,  323 

lower  third,  323 
upper  third,  323 
sciatic,  330 
subclavian,  318 

in  first  portion,  318 
in  second  portion,  318 
in  third  portion,  319 
temporal,  327 
thyroid,  inferior,  320 

superior,  319 
tibial,  anterior,  332 

posterior,  333 
ulnar,  324 

at  junction  of  upper  and  middle  thirds 

of  arm,  324 
in  lower  third,  324 
vertebral,  321 
to  control  hemorrhage,  337 
treatment  of  aneurysm  by,  918 
Ligature-carrier,  313 
Ligatures,  280,  314 

of  blood-vessels,  absorption  of,  138 
Lightning,  effects  of,  116 
Lightning-stroke,  116 
symptoms,  117 
treatment,  118 
Line  of  demarcation,  215 
Lingual  artery,  ligature  of,  326 

dermoids,  499 
Lint  poultice,  424 
Lipoma  arborescens,  474 
Lipomata,  473 
diffuse,  473 
intermuscular,  474 
intramuscular,  474 
meningeal,  475 
nasal,  496 
periosteal,  475 
subcutaneous,  473 
submucous,  474 
subserous,  474 
subsynovial,  474 
Liquor  puris,  65 
Lisfranc's  amputation,  349 
at  shoulder-joint,  346 
Local  anesthesia,  453 

by  infiltration,  431,  455 
cocain,  429,  454 
ethyl  chlorid,  454 
eucain,  432,  455 
holocain,  455 
in  minor  surgery,  428 
application  of  cold,  426 

of  heat,  422 
asphyxia,  230 
blood-letting,  433 
infection,  57 

conditions  favorable  for,  59 
immunity  to,  58 
syncope,  230 
Localization,  cerebral,  792 


Loffler's  alkaline  methylene  blue,  27 
blood-serum  mixture,  24 
method  of  staining  flagella,  28 
Long  saphenous  nerve,  injury  of,  891 
Loom'  bodies  in  joints,  722 
symptoms,  722 
treatment,  723 
cartilages  of  joints,  475 
Loss  of  power  in  fractures,  509 
Lossen's   excision   of  second   division  of  tri- 
facial, 875 
Lower  extremity,  spiral   reversed  bandage  of, 
412 
jaw,  dislocation  of,  613 
fracture  of,  529 
diagnosis,  530 
prognosis,  530 
treatment,  530 
Liicke's  excision  of  second  division  of  trifacial, 

875 
Lumbar  abscess  in  Pott's  disease,  847 
treatment,  851 

plexus,  injuries  of,  891 
Lumpy-jaw,  201 
Lupus  colloide,  249 

diagnosis,  249 

eleve,  248 

erythematosus,  251 

exedens,  248 

exfoliativus,  248 

exulcerans,  248 

localities  of,  248 

maculosus,  248 

myxomateux,  249 

of  mucous  membranes,  249 

of  penis,  262 

papillaris  verrucosus,  248 

phagedenique,  248 

prognosis,  249 

serpiginosus,  248 

treatment,  249 

tumidus,  248 

vorax,  248 

vulgaris,  247 
Lustgarten,  bacillus  of,  34 
Luxatio  erecta  of  humerus,  619 

horizontalis  of  humerus,  619 
Lymphadenitis  from  septicemia,  152 

tuberculous,  251 
diagnosis,  252 
pathological  anatomy,  252 
symptoms,  252 
treatment,  252 
Lymphangiectasis,  931 
Lymphangioma,  479,  931 

cavernous,  480 
Lymphangitis,  acute,  928 

chronic,  929 

from  septicemia,  152 

peripheral,  928 

tubular,  928 
symptoms,  929 
treatment,  929 
Lymphatic  cysts,  480 

glands  and  the  resorption  of  bacteria,  149 
surgery  of,  933 

leukemia,  435 

nevus,  480 

system,  surgery  of,  922 

vessels,  surgery  of,  927 
wounds  of,  927 
Lymph-gland  infection  of  tumors,  471 
Lymph-glands,  primary  tumors  of,  935 


INDEX. 


953 


Lymph-glands,  sarcoma  of,  936 
Lymph-passages,  transmission  of  pus-microbes 

by,  148 
Lymph-scrotum,  930 

blood-examination  in,  86 
Lymphoid  corpuscles  of  tubercle,  245 
Lymphoma,  malignant,  935 
Lvmphorrhea,  930 
l.\  mphosarcoma,  483,  935 
Lysol,  277 
Lyssa,  190 

Macewen's  supracondyloid  osteotomy,  378 
Macrocheilia,  932 

Microglossia,  932 
Madura-foot,  208 

morbid  anatomy,  208 
symptoms,  210 
treatment,  210 
Mai  perforans,  j-j 
Malar  bone,  fracture  of,  527 

treatment,  528 
Malgaigne's  racket  amputation  of  metacarpal 

bones,  342 
Malignant  diseases,  pathology  of  blood  in,  84 
edema,  197 

bacteriology  of,  38 
lymphoma,  935 
tumors,  characters  of,  466 
dissemination  of,  471 
of  bone, 701 
Mallein,  200 
Malleus  humidus,  198 
Many-tailed  bandage,  407 
Marmorek's  antistreptococcic  serum,  169 

culture  media,  24 
Massage  in  contusions,  104 

in  inflammation,  54 
Maxilla,  inferior,  excision  of,  387 

superior,  excision  of,  384 
Mayo-Robson's  operation  for  spina  bifida,  838 
Mayor's  hammer,  422 

handkerchief  dressings,  407 
Meat-water,  23 

Mechanical  cleansing  in  aseptic  surgery,  272 
Meckel's  ganglion,  excision  of,  875 
Median  nerve,  branch  of,  in  hand,  injuries  of, 
890 
injury  of,  890 
Mediotarsal  amputation,  350 
Melanosarcomata,  484 
Melon-seed  bodies,  260 
Meningeal  lipomata,  475 
Meningitis,  secondary,  812 
traumatic,  811 
tuberculous,  254 
Meningocele,  790,  819,  836 

clinical  history,  837 
Meningo-encephalocele,  819 
Meningomyelocele,  836 
clinical  history,  837 
diagnosis,  differential,  838 
Mental  state,  influence  on  repair,  no 
Mercury  in  inflammation,  56 

injections  of,  436 
Metacarpal  bones,  amputation  of,  341 
excision  of,  392 
fracture  of,  572 

Malgaigne's  racket  amputation  of,  342 
thumb,  dislocation  of,  642 
Metacarpophalangeal         joint,         amputation 
through,  341 
dislocation  of,  643 


Metacarpophalangeal  joint  of  fingers,  disloca- 
tion of,  645 
Metacarpus,  dislocation  of,  642 
Metastatic  erysipelas,  175 
Metatarsal  bone,  amputation  of,  349 
disarticulation  of,  349 
excision  and  resection  of,  395 
fracture  of,  596 
Metatarsophalangeal  joints,  dislocation  of,  658 
Metatarsus,  dislocation  of,  658 
Methyl  violet,  27 

Methylene  bichlorid  as  an  anesthetic,  444 
blue,  27 

Kuhne's,  27 
Loffler's,  27 
Metschnikoff's  theory,  49 
Michon's  operation  for  rhinoplasty,  401 
Micrococci,  17 

development  of,  17 
Micrococcus  Pasteuri,  34 

tetragenus,  31,  58 
Miliary  tubercle,  241 
Milk-leg,  906 
Milzbrand,  194 
Miner's  elbow,  782 
Minor  surgery,  404 

anesthetics  in,  427 
Mixed  fracture,  507 

Mixter's  excision  of  second  and  third  divisions 
of  fifth  nerve,  876 
of  third  division  of  fifth  nerve,  875 
Mobility,  abnormal,  in  fractures,  508 
Moist  gangrene,  214 

heat,  application  of,  423 
Mole,  hairy,  479 
Moles,  500 

Molluscum  fibrosum,  478 
Morbid  growths  after  fracture,  522 
Mordants,  27 
Mortification,  213 
Morve,  198 

Motor  nerves  of  lower  abdominal  muscles,  in- 
juries of,  891 
Moulded  splints,  514 
Mouse  septicemia,  147 
Mouth,  sterilization  of,  293 
Mucous  bursas,  780 

membranes,  lupus  of,  249 
tuberculosis  of,  247 
Multiple  fracture.  505,  507 
Mural  implantation  of  bacteria,  154 
Muscle-callus,  129 
Muscles,  atrophy  of,  771 
contractures  of,  772 
contusion  of,  763 
prognosis,  763 
signs,  763 
treatment,  763 
diseases  of,  770 
functional  disorders  of,  772 
hernia  of,  764 
hypertrophy  of,  770 
inflammation  of,  770 
svmptoms,  770 
treatment,  770 
repair  of,  129 
rupture  of,  764 
sprain  and  strains  of,  764 
syphilitic  disease  of,  770 
tuberculosis  of,  261,  770 
tumors  of,  773 
wounds  of,  768 
treatment,  769 


954 


INDEX. 


Muscular  contraction,  fracture  by,  507 

spasm  after  fracture,  520 
in  fractures,  509 
surgical  treatment  of,  881 
Musculocutaneous  nerve,  injuries  of,  890 
Musculospiral  nerve,  injuries  of,  889 
Mustard  foot-bath,  425 

I  ilaster,  425 
Mycetoma,  208.      See  Madura  foot. 
Myelocele,  835 

clinical  history,  837 
Myeloid  sarcoma  of  bone,  701 
Myelomata,  481,  482 
Myosite  infectieuse,  161 
Myositis,  770 

symptoms,  770 

treatment,  770 
Myxoma,  792 
Myxomata,  477 

Nail  horns,  491 
Nasal  bones,  fracture  of,  525 
lipomata,  496 

process  of  superior  maxilla,  fracture  of,  525 
septum,  displacement  of,  526 
Nasopharyngeal  polyps,  resection  of  palate  for, 

386 
Neck,  hydrocele  of,  480 

of  femur,  osteotomy  of,  376 
Necrosis  of  bone,  682 
acute,  677 
after  fracture,  520 
symptoms,  682 
treatment,  683 
phosphorus,  693 
treatment,  694 
quiet,  684 
Needles,  314 

Needling  for  aneurysm,  917 
Negative  chemiotaxis,  19 
Nelaton's  excision  of  shoulder-joint,  366 
Nephrophthisis,  266 

Nephrotomy  in  tuberculosis  of  the  kidney,  267 
Nerve,  anterior  crural,  injury  of,  891 
auditory,  injury  of,  886 
buccal,  avulsion  of,  875 
cervical  sympathetic,  surgery  of,  892 
circumflex,  injury  of,  889 
contusion  of,  131 
crushing  of,  866 
diagnosis,  866 
treatment,  867 
facial,  injury  of,  886 
fifth,  excision  of  second  division  of,  875 
of  second  and  third  divisions  of,  876 
of  third  division  of,  875 
neurectomy  of,  873 
fourth,  injury  of,  886 
frontal,  avulsion  of,  874 
genitocrural,  neurectomy  of,  891 
glossopharyngeal,  injury  of,  887 
gustatory,  avulsion  of,  874 
hypoglossal,  injury  of,  888 
iliohypogastric,  injury  of,  891 
ilio-inguinal,  injury  of,  891 
inferior  dental,  avulsion  of,  874 
infra-orbital,  avulsion  of,  874 
intercostal,  neuralgia  of,  890 
laceration  of,  866 
diagnosis,  866 
treatment,  867 
long  saphenous,  injury  of,  891 
median,  injury  of,  890 


Nerve,  musculocutaneous,  injuries  of,  890 

musculospiral,  injuries  of,  889 

olfactory,  injury  of,  885 

optic,  injury  of,  885 

phrenic,  injuries  of,  888 

pneumogastric,  injury  of,  887 

popliteal,  injury  of,  891 

posterior  rotatores,  operations  on,  882 
tibial,  lesion  of,  892 

recurrent  laryngeal,  lesions  of,  887 

repair  of,  130 

sarcoma  of,  883 

sciatic,  neuralgia  of,  891 

section  of,  866 
diagnosis,  866 
treatment,  867 

sixth,  injury  of,  886 

spinal  accessory,  operations  on,  882 
surgery  of,  888 

supra-orbital,  avulsion  of,  874 

third,  injury  of,  886 

tumors,  883 

ulnar,  injury  of,  890 
Nerve-avulsion,  872 
Nerve-grafting,  871 

prognosis,  871 
Nerve-reproduction  after  suture,  869 
Nerve-roots,  posterior,  division  of,  881 

pressure  on,  in  Pott's  disease,  847 
Nerve-stretching,  865,  871 
Nerve-suture,  867 
Nerves,  bulbous,  885 

contusions  of,  862 
symptoms,  862 
treatment,  863 

dislocation  of,  866 
causes,  866 
treatment,  866 

operations  on,  867 

peripheral,  surgery  of,  862 

pressure  on,  863 

wounds  of,  862 
Neural  arch,  fracture  of,  825 

cysts,  504 
Neuralgia,  brachial,  operative  treatment  of,  881 

of  lower  extremity,  surgical  treatment  of,  881 

operative  treatment  of,  872 

trifacial  neurectomy  in,  873 
Neurectomy,  872 

in  trifacial  neuralgia,  873 

of  genitocrural  nerve,  891 

of  spinal  accessory  nerve,  882 
Neurofibromatosis,  477 
Neurolipomata,  475 
Neuroma,  plexiform,  479 
Neuromata,  883 

ganglionis,  478 

symptoms  of,  884 

treatment,  884 
Neuromimesis,  721 

diagnosis,  721 

treatment,  721 
Neuropathic  arthritis,  720 
Neuroplasty,  870 
Neurotomy,  872 
Nevi,  cavernous,  479 
Nevolipomata,  473,  479 
Nevus,  911 

lymphatic,  480 

simple,  479 
Nitrous  oxid,  457 
and  ether,  460 
and  oxygen  anesthesia,  458 


INDEX. 


955 


Nitrous  oxid  anesthesia  in  minor  surgery,  42S 
Nitzche's  linseed-oil  varnish  in  burns,  114 
Noma  of  vulva,  235 

treatment,  236 
Non-suppurative  inflammation  of  bone,  675 
Non-union  of  fracture,  524 
Nose,  fracture  of,  525 
treatment,  526 

plastic  surgery  of,  400 

sterilization  of,  293 
Nuclein,  59 

Nucleins  in  wound  fever,  142 
Nussbaum's  excision  of  second  division  of  tri- 
facial, 875 
Nutrient  bouillon,  23 

gelatin,  22 

media  for  bacteria,  22 
Nutritive  enema,  injection  of,  438 

Oblique  bandage,  406 
Occipital  artery,  ligature  of,  327 
Occipito-atloid  disease,  symptoms,  846 

dislocation,  824 
Odontomes,  476 
composite,  476 
compound  follicular,  476 
epithelial,  476 
fibrous,  476 
follicular,  476 
radicular,  476 
CEdeme  charbonneux,  197 
Old  dislocations,  611 
of  elbow,  635 
of  humerus,  629 
Olecranon,  fracture  of,  556 
symptoms,  557 
treatment,  557 
Olfactory  nerve,  injury  of,  885 
Ollier's  excision  of  elbow-joint,  367 
of  hip-joint,  371 
of  scapula,  390 
of  shoulder-joint,  365 
of  superior  maxilla,  385 
method  of  rhinoplasty,  401 
osteoplastic  method  of  rhinoplasty,  403 
Open  fracture,  507 
Operating  gloves,  291 
rooms  and  furniture,  306 
table,  301,  307 
theatres,  309 
Operation,  aseptic,  conduction  of,  300 
blood-regeneration  after,  80 
preparation  of  field  of,  292 
of  operator  for,  287 
of  patient  for,  292 
room  for,  300 
Operations,  instruments  for,  312 

on  nerves,  867 
Operative  surgery,  312 
Operator,  clothing  of,  288 

preparation  of,  for  operation,  287 
Optic  nerve,  lesions  of,  885 
Orange-colored  pus,  66 
Orbit,  fracture  of,  801 
Orchitis,  tubercular,  263 
Os  calcis,  dislocation  of,  657 

fracture  of,  596 
Os  magnum,  dislocation  of,  641 
Osteitis  deformans,  698 
prognosis,  698 
treatment,  698 
Osteoarthritis,  709 
of  knee,  740 


Osteomalacia,  697 

treatment,  698 
Osteomata,  475 
cancellous,  475 
compact,  475 
of  skull,  791 
Osteomyelitis,  acute,  675 
diagnosis,  678 
prognosis,  678 
result  of,  677 

resulting  after  open  wound,  681 
symptoms,  677 
treatment,  679 
chronic,  684 
etiology,  685 
symptoms,  685 
treatment,  685 
of  skull,  790 
of  vertebra;,  acute,  840 
tuberculous,  687 
symptoms,  688 
Osteotomy,  375 
cuneiform,  376 

for  ankylosis  of  knee-joint,  379 
for  flat-foot,  381 
for  genu  valgum,  378 
for  hallux  valgus,  380 
for  inveterate  club-foot,  380 
for  talipes  equinovarus,  381 
for  talipes  equinus,  381 
Macewen's  supracondyloid,  378 
of  femur  for  ankylosis  of  hip,  376 

for  genu  valgum,  378 
of  shaft  of  femur  on  outer  side,  378 
of  tibia,  379 

below  tuberosities,  379 
cuneiform,  380 
linear,  379 
Ostitis  alter  typhoid  fever,  675 

treatment  of,  675 

Otogenic  pyemia,  163 

sinus  phlebitis,  163 

I  K.il  amputation,  340 

Ovarian  dermoids,  500 

teeth,  501 
Oxalic  acid,  277 

Pachyderm  vtocele,  788 

Pads,  284 

Pain  after  fracture,  521 

as  a  symptom  of  inflammation,  51 

in  fracture,  509 

of  wounds,  89 
Palate,  hard,  resection  of,  for  nasopharyngeal 
polyps,  386 
anterior  portion,  386 
Palmar  abscess,  72 

fascia,  Dupuytren's  contraction  of,  776 
Panaritium,  72 
Papilloma,  489 

intracystic,  490 

villous,  489 
Paquelin's  cautery,  423 
Paracentesis  thoracis  in   tuberculous   pleurisy 

and  empyema,  255 
Paraffin  bandage,  410 
Paralysis  after  fracture,  519,  521 

crutch-,  after  fracture,  522 

facial,  886 

hyperemia  of,  44 

of  recurrent  laryngeal  nerve,  888 

pressure-,  863 
treatment,  865 


956 


INDEX. 


Paralysis,  Saturday-night,  131 
Paraplegia,  compression,  848 
Parasitic  cysts,  504 

fetus,  501 
Parkhill's  fracture  clamp,  515 
Passive  hyperemia,  45 
Patella,  disli  icatii  m  of,  649 
frequency,  649 
fracture  of,  586 
symptoms,  588 
treatment,  588 
suturing  of,  589 
Pathological  dislocations,  613 

fracture,  507 
Patient,  preparation  of,  for  operation,  292 
Pelvic  bones,  resection  of,  389 
Pelvis,  fracture  of,  572 
Pendulum    method   of   treating  dislocation   of 

humerus,  628 
Penetrating  fracture,  505 

u  ounds,  88 
Penis,  lupus  of,  262 
tuberculosis  of,  261 

tuberculous  ulceration  of  dorsum  of,  261 
Peptone  solution,  Dunham's,  24 
Perforating  wounds,  88 
Peri-adenitis  from  septicemia,  152 
Pericarditis,  suppurative,  operative    treatment 

of,  895 

Pericardium,  wounds  of,  894 

symptoms,  894 

treatment,  894 

Perinephritic  abscess,  73 

Periosteal  lipomata,  475 

Periosteum,  inflammation    of,  675.     See  Peri- 
ostitis. 
Periostitis,  acute  non-suppurative,  675 
suppurative,  675 
treatment  of,  679 
after  typhoid  fever,  675 

treatment  of,  675 
albuminous,  695 
chronic,  684 
etiology,  685 
symptoms,  685 
treatment,  685 
of  skull,  790 

resulting  after  an  open  wound,  681 
tuberculous,  687 
Peripheral  lymphangitis,  928 

nerves,  surgery  of,  862 
Peritoneum,   tuberculosis  of,  258.     See   Tuber- 
culosis of  the  peritoneum. 
Peritonitis,  tuberculous,  258.     See  Tuberculosis 

of  the  peritoneum . 
Peri-urethritis,  tuberculous,  261 
Petit's  tourniquet,  337 
Phagedena,  237 
Phagedenic  ulcers,  78 
Phagocytes,  49 
Phalanges,  excision  of,  392 
and  resection  of,  395 
fracture  of,  572 
of  toes,  fracture  of,  596 
Pharynx,  sterilization  of,  294 
Phlebitis,  905 

otogenic  sinus,  163 
suppurative,  905 
treatment,  171 
symptoms,  906 
treatment,  906 
Phlebolith,  908 
Phlebotomy,  434 


Phlegmasia  alba  dolens,  906 

Phleg 1 5  erj  sipelas,  176 

inflammation,  73 

treatment,  74 
Phlogosin,  145 
Phosphorous  necrosis,  693 

treatment,  694 

Phrenic  nerve,  injuries  of,  888 

Phthisic  testis,  263 

Picric  acid,  27 

Pirogoff's  amputation,  352 

Pisiform  bone,  dislocation  of,  641 

Plantaris  muscle,  rupture  of,  765 

Plaster  bandage,  408 

Gigli's  method  of  applying,  408 
in  fractures,  513 

Say  re's  method  of  applying,  408 
dressing,  interrupted,  409 
mustard,  425 
Plastic  surgery,  395 

direct  union  of  freshened  edges,  396 
Indian  method,  398 
Italian  method,  398 
lateral  displacement,  396 
method  of  flap-formation,  398 

of  gliding,  396 
of  deformities  after  burns,  399 
repair  of  elliptical  defects,  398 
Weber's  operation,  398 
of  quadrilateral  defect,  398 
Letenneur's  method,  398 
Briins'  operation,  398 
of  triangular  defect,  398 
Burow's  operation,  397 
Dieffenbach's  operation,  397 
Jaesche's  operation,  397 
rhinoplasty,  400.     See  also  Rhinoplasty. 
Plate-cultures,  24 
Pleurisy,  tuberculous,  255 
Plexiform  angioma,  479 

neuroma,  479 
Plexus,  brachial,  injuries  of,  889 
cervical,  injuries  of,  888 
lumbar,  injuries  of,  891 
Pneumatocele,  786 
Pneumogastric  nerve,  lesions  of,  887 
Pneumonia,  diplococcus  of,  34 
Pointing  of  an  abscess,  64 
Poisoned  wounds,  105 
symptoms,  106 
treatment,  107 
Popliteal  aneurysm,  919 
artery,  ligature  of,  331 
nerves,  injury  of,  891 
Port- wine  stain,  479 

Position,  control  of  hemorrhage  by,  337 
Positive  chemiotaxis,  19 

Posterior  nerve-roots,  division   of,  for  neural- 
gia, 881 
rotatores,  operations  upon,  882 
tibial  nerve,  lesion  of,  892 
Postesophageal  abscess  in  Pott's  disease,  846 
Postoperative  fever,  blood  in,  86 

treatment  of  wounds,  299 
Postpharyngeal    abscess     in     Pott's     disease, 
846 
treatment,  851 
Potassium  permanganate,  277 
Potato  culture-medium,  24 
Pott's  disease,  840 

angular  curvature  in,  843 
course,  842 
definition,  840 


INDEX. 


957 


Pott's  disease,  diagnosis,  848 
etiology,  840 
pathology,  841 
pressure  upon  nerve-roots  in,  847 

upon  spinal  cord  in,  844 
prognosis,  848 

reduction  of  deformity  in,  853 
suppuration  in,  844 
symptoms,  844 
abscess,  846 
hyperesthesia,  845 
pain,  844 

rigidity  of  spine,  845 
treatment,  849 
by  rest,  849 
by  supports,  849 
operative,  851 
fracture,  593 
Poultice,  flaxseed,  424 
Poultices,  424 

Prepatellar  bursa,  inflammation  of,  781 

Pressure,  control  of  hemorrhage  by,  337 

on  nerve-roots  in  Pott's  disease,  847 

on  spinal  cord  in  Pott's  disease,  848 

Pressure-paralysis,  863 

treatment,  865 
Primary  anesthesia,  453 
in  minor  surgery,  428 
septicemia,  156 
Prostate,  tuberculosis  of,  262 
Protrusion  of  brain-membranes,  819 

treatment,  819 
Provisional  callus,  132 
Psammomata,  490 
Pseudocysts,  503 
Pseudoleukemia,  85,  935 
Psoas  abscess  in  Pott's  disease,  847 
treatment,  851 
muscle,  rupture  of,  768 
Pubic  bone,  fracture  of,  572 
Pubofemoral  ligament,  660 
Pudic  artery,  internal,  ligature  of,  330 
Puncture    in    tuberculous    pleurisy    and    em- 
pyema, 255 
Punctured  fracture,  505 

of  skull,  802 
Purgatives  in  inflammation,  56 
Pus,  65 
blue,  66 

bonum  et  laudabile,  168 
-corpuscles,  65 
laudable,  66 

-microbes,  dissemination  of,  148 
microscopical  examination  of,  66 
orange-colored,  66 
red,  66 

tuberculous,  66 
Pustula  maligna,  194.     See  Anthrax. 
Pustule,  67 

Pyelitis,  tuberculous,  266 
Pyelonephritis,  266 
Pyemia,  147 

bacteriology  of  the  blood  in,  85 
course  of,  158 
diagnosis,  164 
otogenic,  163 
symptoms,  158 
treatment,  171 
Pylephlebitis,  163 

septic,  treatment  of,  171 
Pyogenic  bacteria,  dissemination  of,  148 
cocci,  58 
organisms,  local  action  of,  60 


Quadriceps  extensor  tendon,  rupture  of,  767 
Quadrilateral  defect,  plastic  repair  of,  398 
Brims'  operation,  398 
Letenneur's  operation,  398 
Quiet  necrosis,  684 

RABIES,  190.     See  Hydrophobia. 
Racket  method  of  amputation,  341 
Radial  artery,  ligature  of,  323 
Radicular  odontomes,  476 
Radius,  dislocation  of,  637 
causation,  637 
diagnosis,  639 
frequency,  637 
symptoms,  637 
treatment,  639 
and  ulna,  dislocation   of,  630.     See   Elbow- 

joint,  dislocation  of. 
excision  and  resection  of,  392 
fracture  of  coronoid  process  of,  559 
of  head  of,  559 
of  lower  extremity  of,  563 
diagnosis,  568 
prognosis,  568 
treatment,  569 
of  shaft  of,  562 
subluxation  of  head  of,  639 
Rage,  190 
Railway-spine,  833 
Ranula,  503 
Ray-fungus,  201 
Raynaud's  disease,  213 
gangrene,  230 
symptoms,  231 
treatment,  231 
Rectal  dermoids,  499 
etherization,  448 
tube,  use  of,  437 
Rectus  abdominis,  rupture  of,  768 
Recurrent  bandage,  407 
of  head,  420 
of  stump,  420 
laryngeal  nerve,  lesions  of,  888 
Red  pus,  66 

Redness  as  a  symptom  of  inflammation,  50 
Redressing  of  wounds,  103 
Reef-knot,  338 

Re-formation  of  the  callus,  132 
Relaxation-sutures,  100 
Repair.     See  also  Healing. 
age  and,  no 

hygienic  conditions  and,  109 
influences  affecting,  109 
mental  state  and,  no 
of  arteries,  135 
of  bone,  131 
of  cartilage,  133 
of  glands,  139 
of  muscle,  129 
of  nerve,  130 
of  skin,  125 
of  special  tissues,  125 
of  subcutaneous  connective  tissue,  125 
of  tendon,  128 
Resection  of  bone,  364 
of  clavicle,  390 
of  femur,  393 
of  fibula,  393 
of  hard  palate,  anterior  portion,  386 

for  nasopharyngeal  polyps,  386 
of  humerus,  391 
of  inferior  maxilla,  387 
of  lower  jaw  for  ankylosis,  389 


958 


INDEX. 


Resection  of  metatarsal  bones,  395 
of  pelvic  bones,  392 
of  radius,  392 
•  it  ribs,  389 

Estlander's  operation,  389 
Schede's  operation,  390 
of  scapula,  390 
of  sternum,  389 
of  tibia,  393 
of  ulna,  391 

of  ununited  fracture,  382 
of  upper  jaw,  Von  Langenbeck's,  386 
Resorption  fever,  142 
Rest  in  inflammation,  54 
Retention  cysts,  502 
Reticular  lymphangitis,  928 
Retractors,  313 

for  amputations,  339 
Retrocollis,  882 
Revision  of  dressings,  103 

Reyher's  excision  of  second  division  of  trifa- 
cial, 875 
Rheumatic  arteritis,  903 
arthritis,  acute,  707 
gout,  709 
Rheumatism,  gonorrheal,  712 
of  elbow,  748 
of  wrist,  acute,  748 
gonorrheal,  748 
Rheumatismus  blennorrhoicus,  712 
Rheumatoid  arthritis,  709 
Rhigolene,  454 
Rhinoplasty,  400 

for  elevation  of  bridge  of  nose,  401 
for  loss  of  columna,  401 

Sedillot  s  method,  401 
for  loss  of  septum  and  nasal  bones,  401 
Dieffenbach's  method,  401 
Ollier's  method,  401 
Verneuil's  operation,  401 
for  loss  of  surface  of  septum,  Indian  method, 

401 
for  superficial  defect,  400 

Denonvillier's  method,  400 
Michon's  operation,  401 
Von  Langenbeck's  method,  400 
Italian  method,  403 
Ollier's  osteoplastic  method,  403 
Tagliacozzian  method,  403 
Von  Langenbeck's  method,  402 
Rhinoscleroma,  bacteriology  of,  39 
Ribbail's  bandage,  413 
Rib-resection,  drainage  by,  257 
Ribs,  fracture  of,  534 
course,  536 
symptoms,  536 
treatment,  537 
resection  of,  389 
Rice  bodies,  260 
Rickets,  694 
etiology,  694 
scurvy,  697 

treatment  of,  697 

symptoms,  694 

treatment,  696 

Riders'  bone,  764 

Rodent  ulcer,  496 

Rolando,  fissure  of,  location  of,  796 
Roll-cultures,  Esmarch's,  24 
Rose's  method  of  excising  Gasserian  ganglion, 

879 
Rotz,  198 
Round-celled  sarcoma,  482 


Round-celled  sarcoma  of  bone.  701 

Roux's  amputation,  352 

Rubber  goods,  sterilization  of,  286 

plaster,  421 
Rubor,  50 
Rupture  of  abdominal  muscles,  768 

of  artery,  899 
treatment,  900 

of  biceps  of  arm,  765 

of  ligamentum  patella;,  767 

of  muscles,  764 

of  plantaris  muscle,  765 

of  psoas,  768 

of  rectus  abdominis,  768 

of  sternomastoid,  768 

of  tendo  Achillis,  768 

of  tendon  of  quadriceps  extensor,  767 

of  tendons,  764 

of  triceps,  768 

of  vein.  900 

Sacculated  aneurysm,  914 

Sacral  disease,  846 

Sacrococcygeal  disease,  symptoms,  846 

tumors,  congenital,  839 
Safranin,  27 

Sagittal  dislocation  of  foot,  652 
Salicylic  acid,  277 
Saline  fluid,  intravenous  injection  of,  435 

infusions  in  shock,  123 
Salt-solution  as  a  disinfectant,  277 
Salzer's  excision  of  third  division  of  fifth  nerve, 

875 
Sanies,  66 

Saphenous  nerve,  long,  injury  of,  891 
Sapremia,  143 

prognosis  of,  144 

symptoms  of,  144 

treatment,  145 
Sarcocele,  tubercular,  263 
Sarcoma,  alveolar,  484 

of  brain,  814 

of  lymph-glands,  936 

of  nerve,  883 

of  skull,  792 

of  spinal  column,  855 

round-celled,  482 

spindle-celled,  483 
Sarcomata,  482 

distribution  of,  486 

general  characters  of,  484 

of  bone, 700 
treatment,  701 
Saturday-night  paralysis,  131 
Saw,  Adams's,  377 
Sayre's  jacket  for  Pott's  disease,  830 

jurv-mast,  851 

method  of  applying  plaster  bandage,  408 
Scalds,  in 

prognosis  of,  113 
Scalp,  abscess  of,  785 

anatomical  peculiarities  of,  784 

aneurysm  of,  789 

anthrax  of,  789 

blood-tumors  of,  779 

carbuncle  of,  786 

cellulitis  of,  785 

dermoid  cysts  of,  787 

epithelioma  of,  789 

erysipelas  of,  785 

fatty  tumors  of,  788 

fibroma  of,  788 

gangrene  of,  786 


INDEX. 


959 


Scalp,  hematoma  of,  786 
horns  of,  787 
injuries  of,  784 
keloid  of,  788 
malignant  tumors  of,  789 
sterilization  of,  294 
tumors  of,  786 
ulcers  of,  786 
vascular  tumors  of,  789 
Scalpel,  313 

manner  of  holding,  315 
Sc  iphoid  bone,  dislocation  of,  641,  658 
Scapula,  dislocation  of,  617 
causation,  617 
diagnosis,  618 
frequency,  617 
pathology,  617 
prognosis,  618 
subclavicular,  617 
symptoms,  617 
treatment,  618 
upward,  618 
excision  and  resection  of,  390 
fracture  of,  542 
diagnosis,  543 
treatment,  544 
Scar-tissue,  injuries  and  diseases  of,  127 
Schede's  resection  of  ribs,  390 
Schimmelbusch  sterilizer,  274 
Schleich's  anesthetic  mixtures,  431 
infiltration  anesthesia,  455 
in  minor  surgery,  431 
Schwartz's  operation  for  flat-foot,  382 
Sciatic  artery,  ligature  of,  330 
nerve,  neuralgia  of,  891 

relation  of,  to  hip-dislocation,  661 
Scoliosis,  857 
pathology,  857 
symptoms,  859 
treatment,  859 
exercises,  860 
rest,  860 
supports,  861 
Scrofuloderma,  250 
Scrofulous  gummata,  250 
nodes,  250 
orchitis,  263 
Scrotum,  lymph-,  930 
Scurvy  rickets,  697 
treatment  of,  697 
Sebaceous  adenomata,  496 
carcinoma,  496 
cysts,  495 

glands,  adenomata  and  carcinomata  of,  495 
horns,  491 
Second  intention,  healing  by,  91 
Secondary  hemorrhage,  898 
meningitis,  812 
septicemia,  156 
Section  of  nerve,  866   . 
Sedative  poultice,  424 
Sedillots  amputation  of  leg,  355 
of  metatarsal  bone,  353 
of  thigh,  360 
method  of  rhinoplasty,  401 
Selva's  thumb-bandage,  412 
Semilunar  bone,  dislocation  of,  641 

cartilages,  dislocation  of,  723 
Seminal  vesicles,  tuberculosis  of,  263 
Senile  gangrene,  222 
Senn's  bloodless  amputation  at  hip-joint,  363 

bone-cylinders  and  ferrules,  515 
Sensorimotor  area,  793 


Sepsis,  270 

Septic  gangrene,  233 

inflammation,  57 

intoxication,  145 

clinical  course  of,  146 
diagnosis,  146 

pylephlebitis,  treatment,  171 
Septicemia,  147 

bacteriology  of  the  blood  in,  85 

course  of,  155 

diagnosis,  164 

differential  diagnosis,  166 

mouse,  147 

pathological  anatomy,  151 

primary,  150 

secondary,  156 

symptoms,  155 

treatment,  168 
Septicopyemia,  147,  158 
Septum  of  nose,  displacement  of,  526 
Sequestra,  682 
Sequestration  dermoids,  497 
Sequestrum,  syphilitic,  692 

treatment,  693 

Serous  membranes,  tuberculosis  of,  254 

Serpents,  bites  of,  210 

symptoms,  211 

treatment,  211 

varieties  of,  210 
Serum-therapeutic^,  40 
Serum-therapy  in  snake-bite,  211 

of  septicemia  and  pyemia,  168 

of  tetanus,  187 
Sessile  exostoses,  699 
Seutin's  bandage,  410 
Shock, 118 

blood-examination  in,  81 

delayed,  119 

diagnosis  of,  120 

erethistic,  122 

in  fractures,  509 

saline  infusions  in,  123 

stage  of  reaction  of,  120 

symptoms  of,  119 

treatment  of,  120 
Shortening  of  limb  in  fractures,  509 
Shoulder,  amputation  at,  346 

arthritis  of,  745 

dislocation   of,  619.     See   Humerus,  disloca- 
tion of. 
frequency,  630 

excision  of,  364.     See  Excision  of  shoulder- 
joint. 

rheumatism  of,  745 

spica  bandage  of,  416 

sprain  of,  744 
Silicate  of  soda  bandage,  410 

in  fractures,  514 
Silk  sutures,  sterilization  of,  283 
Silkworm-gut,  sterilization  of,  283 
Silver  wire,  sterilization  of,  283 
Simple  fracture,  507 

nevus,  479 

traumatic  fever,  142 
gangrene,  232 
Sinus,  79 

treatment  of,  79 
Sinus-protrusion,  790 
Sinus-thrombosis,  812 
Sixth  nerve,  lesions  of,  886 
Skin,  abscesses  of,  67 

contusions  of,  125 

loss  of  substance  of,  127 


960 


INDEX. 


Skin,  repair  of,  125 

traumatic  inflammation  of,  126 
tuberculosis  1  if,  247 

treatment,  251 
wounds  of,  125 
Skull,  carcinoma  of,  792 
contusions  of,  790 
exostoses  of,  791 
fractures  of,  798 
base  of,  800 
healing,  803 
incomplete,  798 
prognosis,  802 
puncture,  802 
treatment,  803 
vault  of,  799 
gumma  of,  791 

inflammatory  conditions  of,  790 
injuries  of,  790 
in  utero,  791 
non-inflammatory  conditions  of,  790 
osteoma  of,  791 
osteomyelitis  of,  790 
periostitis  of,  790 
sarcoma  of,  792 
Slings,  408 
Sloughing,  213,  214 
Smell,  area  of,  795 
Smith's  disarticulation  at  knee,  357 
Snake-bites,  210 
symptoms,  211 
treatment,  211 
Snap -finger,  779 
Soap  plaster,  421 

Sodium  chlorid  as  a  disinfectant,  277 
Soft  chancre,  bacteriology  of,  33 
Sound  area,  795 
Spasm,  laryngeal,  888 

muscular,  surgical  treatment  of,  881 
Spasmodic      wry-neck,      surgical      treatment, 

881 
Speech-area,  auditory,  794 

visual,  794 
Spence's  amputation  at  shoulder-joint,  347 
Sphacelation,  213 
Spica  bandage,  406 
of  foot,  413 
of  groin,  416 
of  shoulder,  416 
of  thumb,  412 
Spice  bag,  425 
Spina  bifida,  835 

clinical  history,  837 
diagnosis,  838 
occulta,  837 
treatment,  838 
excision,  838 
injection  with  iodin,  838 
operation,  838 
varieties,  835 
Spinal  accessory  nerve,  injury  of,  888 
operations  on,  882 
arthropathy,  720 
canal,  tumors  in,  856 
column,  tumors  of,  651; 
diagnosis,  855 
symptoms,  855 
treatment,  856 
cord,  cocainization  of,  456 

pressure  on,  in  Pott's  disease,  848 
tumors  of,  856 
symptoms,  856 
treatment,  856 


I  Spinal  meningeal  hemorrhage,  830.     See  also 
Hetnatorachis. 


Spindle-celled  sarcoma,  483 

of  bone,  701 
Spine,  acute  osteomyelitis  of,  840 

angular  curvature  of,  in  Pott's  disease,  843 
caries  of,  840 

angular  curvature  in,  843 

course,  842 

definition,  840 

diagnosis,  848 

etiology,  840 

pathology,  841 

pressure  on  nerve-roots  in,  847 

on  spinal  cord  in,  848 
prognosis,  848 
suppuration  in,  844 
symptoms,  844 
abscess,  846 
hyperesthesia,  845 
pain,  844 

rigidity  of  spine,  845 
treatment,  849 
by  rest,  849 
by  supports,  849 
operative,  851 
concussion  of,  832 
symptoms,  833 
treatment,  834 
dislocation  of,  823 
prognosis,  824 
treatment,  824 
fracture  of,  825 

non-operative  treatment,  829 
operative  treatment,  828 
prognosis,  828 
symptoms,  826 
fracture-dislocation  of,  825 
lateral  curvature  of,  857.     See  also  Scoliosis. 
I'ott's  disease  of,  840.     See  Spine,  caries  of. 
railway-,  833 
sprain  of,  823 
symptoms,  823 
treatment,  823 
surgery  of,  823 
tumors  of,  855 
Spinous  process,  fracture  of,  824 
Spiral  bandage,  406 

of  all  the  fingers,  411 
of  foot,  covering  heel,  413 
of  palm  or  dorsum  of  hand,  411 
reversed  bandage,  406 

of  lower  extremity,  412 
of  upper  extremity,  410 
Spirilla,  17 

development  of,  18 
Spleen,  abscess  of,  924 

chronic  enlargement  of,  924 
displacements  of,  924 

treatment  of,  924 
inflammatory  diseases  of,  924 
surgery  of,  923 
traumatic  lesions  of,  923 
tumors  of,  926 
Spleens,  accessory,  927 
Splenectomy,  926 
Splenic  anemia,  925 

fever,  194.     See  Anthrax. 
leukemia,  925 
Splint,  420 

for  fractures,  513 
moulded,  514 
Taylor's  hip-,  732 


IXDEX. 


961 


Splint,  Thomas's  hip-,  731 

knee-,  739 
Splint-sores,  77 
Spondylitis  deformans,  853 
pathology,  853 
sj  mptoms,  854 
treatment,  854 
Sponges,  284 
Spontaneous  fracture,  507 

infection,  151 
Spore-staining,  28 
Spores,  18 

Sprains  of  joints,  598 
results  of,  599 
treatment,  599 

of  muscles,  764 

of  shoulder,  744 

of  spinal  column,  823 

of  tendons,  764 
Spreading  traumatic  gangrene,  234 
Squamous-celled  cancer,  494 
Square  knot,  338 
Staining  of  bacteria,  26 
Staphylococcus,  17 

action  of,  61 

cereus  albus,  31 
flavus,  31 

epidermidis  albus,  31 

pyogenes  albus,  bacteriology  of,  30 
aureus,  bacteriology  of,  30 

in  suppuration,  62 
citreus,  31 
Staphylomycosis,  immunity  to,  169 
Starch  bandage,  410 
Steam,  local  application  of,  424 

sterilization  by,  272 

sterilizers,  273 
Stellate  fracture,  505 
Sterilization  by  chemicals,  275 

by  steam,  272 

heat  in,  272 

in  bacteriological  technic,  21 

methods  of,  271 

of  catgut,  282 

of  dressings,  285 

of  hands  of  operator,  288 

of  horsehair,  283 

of  instruments,  287 

of  ligatures  and  sutures,  280 

of  silk  sutures,  283 

of  silkworm-gut,  283 

of  silver  wire,  283 

of  sponges,  284 

of  water,  279 
Sterilizer,  Kny-Sprague,  274 

Schimmelbusch,  274 

Sterilizers,  steam,  273 

Sternomastoid,  rupture  of,  768 

Sternum,  fracture  of,  533 

symptoms,  534 

treatment,  534 

resection  of,  389 
Stiffness  of  joints  after  fracture,  52I 
Stomach,  lavage  of,  436 

sterilization  of,  294 
Stomach-tube,  use  of,  436 
Strahlenpilz,  201 

-krankheit,  201 
Strains  of  muscles,  764 
Strapping  of  breast,  421 

of  testicle,  421 
Streptococcus,  17 

action  of,  60 

61 


Streptococcus  erysipelatis,  31,  58,  173 

pyogenes,  31 
Streptomycosis,  immunity  to,  169 
Streptothrix  madurae,  208 
Stretching  of  nerves,  865 
Strumous  arthritis,  713 

dactylitis,  687 
Stump,  336 

bad,  336 

recurrent  bandage  of,  420 

utility  of,  337 
Subacromial  dislocation  of  humerus,  619 
Subastragaloid  dislocation    of  foot,  652.     See 

also  Foot,  dislocation  of. 
Subclavian  aneurysm,  921 

artery,  ligation  of,  318 
Subclavicular  dislocation  of  humerus,  619 
Subcoracoid  dislocation  of  humerus,  619 
Subcutaneous  connective  tissue,  repair  of,  126 
traumatic  inflammation  of,  126 

injuries,  treatment  of,  104 

lipomata,  473 
Subdeltoid  bursa,  inflammation  of,  782 
Subfascial  abscess,  71 
Subglenoid  dislocation  of  humerus,  619 
Subgluteal  bursa,  inflammation  of,  783 
Subluxation  of  head  of  radius,  639 
Submiliary  tubercle,  241 
Submucous  lipomata,  474 
Subperiosteal    excision    of    superior    maxilla, 

385 
Subserous  lipomata,  474 
Subspinous  dislocation  of  humerus,  619 
Subsynovial  lipomata,  474 
Sulphuric  ether,  444.     See  also  Ether. 
Superfluous  callus,  133 
Superior  maxillary  bone,  fracture  of,  527 

treatment,  528 
Suppuration,  62 

bacteria  of,  58 

leukocytosis  in,  81 

of  demarcation,  112 

of  joint,  600 

symptoms,  65 
Suppurative  arteritis,  903 

inflammation  of  bone,  675.     See  also  OsitO' 
myelitis,  acute. 

pericarditis,  operative  treatment  of,  895 

phlebitis,  905 
treatment,  171 

tenosynovitis,  773 
Supraclavicular  region,  anatomy  of,  316 
Supracondyloid  fracture  of  humerus,  551 
Supra-orbital  nerve,  avulsion  of,  874 
Suprarenal  capsule,  tumors  of,  487 
Surgeon's  knot,  338 
Surgery,  minor,  404 

operative,  312 

orthopedic,  724 

plastic,  395 
Surgical  anesthesia,  439 

bacteriology,  17 

emphysema  after  fracture,  522 

pathology  of  the  blood,  80 
Suture,  nerve-,  867 

of  axillary  artery,  899 

of  operation  wounds,  296 

of  tendons,  769 
Suture-jar,  282 
Suture-material,  314 
Suture-needles,  314 
Sutures,  280 

relaxation,  100 


962 


INDEX. 


Suturing  of  fractures,  515 

of  wounds,  99 
Swelling  as  a  symptom  of  inflammation,  51 
Sylvius,  fissure  of,  location  of,  796 
Symes's  amputation,  351 
Syncope,  118 

local,  228 
Synovial  bursae,  780 
Synovitis,  702 

diagnosis,  703 

of  ankle,  743 

of  knee,  737 
treatment,  738 

pathology,  702 

treatment,  703 
Syphilis,  bacteriology  of,  34 

of  bone,  691.     See  also  Bone,  syphilis  of. 
hereditary,  693 
Syphilitic  arteritis,  903 

caries  of  bone,  692 

disease  of  muscle,  770 

sequestrum,  692 
treatment,  693 
Syringomyelocele,  836 

clinical  history,  837 

Tagliacozzian  method  of  rhinoplasty,  403 
Tailors'  bursa,  783 
Tait's  bandage,  410 

Talipes  equinovarus,  759.     See  also  Club-foot. 
osteotomy  for,  381 
equinus,  osteotomy  for,  381 
valgus,  756 
diagnosis,  757 
etiology,  757 
symptoms,  757 
treatment,  757 
Tarsometatarsal  disarticulation,  349 
Taste,  area  of,  795 
Taylor's  hip-splint,  732 
T-bandage,  double,  407 

single,  407 
Telangiectasis,  479 
Temporal  artery,  ligature  of,  327 
Tenderness  in  fractures,  509 
Tendo  Achillis,  rupture  of.  768 
Tendon,  healing  of,  128 
lengthening  of,  773 
of  biceps,  rupture  of,  765 
of  quadriceps  extensor,  rupture  of,  767 
Tendon-grafting,  769 

Tendon-sheaths,   inflammation    of,   773.      See 
also    Tenosynovitis. 
tuberculosis  of,  259 
Tendons,  dislocation  of,  768 
rupture  of,  764 
sprains  and  strains  of,  764 
suture  of,  769 
transplantation  of,  771 
tuberculosis  of,  259 
wounds  of,  769 
diagnosis,  769 
treatment,  769 
Tennis  elbow,  764 
Tenosynovitis,  773 
acute  simple,  773 
after  fracture,  522 
chronic,  775 
signs,  775 
treatment,  775 
suppurative,  773 
Tenotomy  for  contracture  of  muscles,  773 
Teratoma  of  head,  788 


Teratomata,  501 

sacrococcygeal,  839 
Testicle,  strapping  of,  421 

tuberculosis  of,  263 
Testis,  "tuberculosis  of,  263 
Tetanus,  183 
acute,  183 
antitoxin,  187 
bacillus  of,  37,  183 
bacteriology  of,  37 
carbolic-acid  treatment,  188 
chronic,  185 
diagnosis,  185 
etiology,  183 
head-,  185 
hydrophobicus,  185 
idiopathic,  183 
pathological  anatomy,  185 
prognosis,  186 
serum-therapy,  187 
treatment,  186 
varieties,  183 
Thecal  whitlow,  773 
Thigh,  amputation  of,  358 
Third  nerve,  lesions  of,  886 
Thomas's  hip-splint,  731 

in  fracture  of  neck  of  femur,  577 
in  fracture  of  shaft  of  femur,  582,  583 
knee-splint,  739 
Thoracentesis    in    tuberculous    pleurisy    and 

empyema,  255 
Thoracic  duct,  wounds  of,  927 
Thoracotomy,  drainage  by,  257 
Thrombophlebitis  from  septicemia,  153 
Thrombosis,  907 
sinus-,  812 
symptoms,  909 
treatment,  908 
Thrombus,  901 
Thumb,  dislocation  of,  643 
causation,  643 
diagnosis,  644 
metacarpal  bone  of,  642 
pathology,  643 
prognosis,  644 
symptoms,  644 
treatment,  645 
spica  bandage  of,  412 
Thumb-bandage,  Selva's,  412 
Thyroid  artery,  inferior,  ligature  of,  320 
superior,  ligature  of,  319 
dislocation  of  hip,  662,  663.     See  also  Hip, 
dislocation  of. 
Tibia,  dislocation  of,  646 

causation  and  classification,  646 
frequency,  646 
pathology,  647 
prognosis,  648 
symptoms,  647 
treatment,  648 
fracture  of,  590 
osteotomy  of,  379 
resection  of,  393 
Tibial  artery,  anterior,  ligature  of,  332 
posterior,  ligature  of,  333 
nerve,  posterior,  lesion  of,  892 
Tibiotarsal  amputation,  351 
Toe,  hammer-,  777 
Toes,  amputation  of,  348 
Tooth  tumors,  476 
Torpid  ulcer,  77 

Torsion,  control  of  hemorrhage  by,  338 
Tourniquet,  337 


JXDEX. 


963 


Toxins,  21 

Tracheotomy  in  complications  of  etherization, 

45° 
Transplantation  of  tendons,  771 
Traumatic  aneurysm,  900,  914 
arteritis,  903 
delirium,  522 
erysipelas,  126 
fracture,  507 
gangrene,  simple,  232 
treatment  of,  232 
spreading,  234 
symptoms,  234 
treatment,  235 
hematomyelia,  831 
inflammation  of  the  skin,  126 

of  the  subcutaneous  connective  tissue,  126 
lesions  of  spleen,  923    - 
meningitis,  811 
Trephining,  820 
for  epilepsy,  821 
for  imbecility,  820 
Triangular  defect,  plastic  repair  of,  396 
Burow's  operation,  397 
Dieffenbach's  method,  397 
Jaesche's  operation,  397 
sling,  408 
Triceps,  rupture  of,  768 

Trifacial  nerve,  excision  of  second  division,  875 
excision  of  third  division,  875 
neuralgia,  neurectomy  in,  873 
Trigger-finger,  779 
Tripper  rheumatismus,  712 
True  aneurysm,  914 
Tubercle,  anatomical,  108,  250 
epithelioid  cells  of,  244 
giant  cells  of,  242 
histology  of,  241 
leukocytes  of,  245 
lymphoid  corpuscles  of,  245 
miliary,  241 
of  brain,  815 
submiliary,  241 
Tubercular  adenitis,  934 
treatment,  934 
disease  of  muscle,  770 
epididymitis,  263 
orchitis,  263 
osteitic  arthritis,  713 
sarcocele,  263 
Tuberculosis,  240 
age  in,  241 
bacteriology  of,  34 

channels  of  entrance  into  the  system,  245 
definition  of,  240 
frequency  of,  240 
general  treatment  of,  246 
incidence  of,  240 
mammae,  253 
of  ankle,  744 
of  bladder,  264 

differential  diagnosis,  265 
symptoms,  265 
treatment,  266 
of  bone,  acute,  686 
of  bursas,  259 

treatment,  260 
of  epididymis,  263 
of  fasciae,  261 

of  genito-urinary  organs,  261 
of  hip-joint,  724.     See  Hip-joint  disease. 
of  kidney,  266 
symptoms,  266 


Tuberculosis  of  kidney,  treatment,  267 
of  muscles,  261 
of  penis,  261 
of  peritoneum,  258 

diagnosis,  258 

treatment,  259 
of  prostate,  262 

diagnosis,  262 

treatment,  262 
of  serous  membranes,  254 
of  skin,  247 

and  mucous  membrane,  247 

treatment,  251 
of  tendons,  259 

treatment,  260 
of  tendon-sheaths,  259 
of  testis,  263 

diagnosis,  264 

prognosis,  264 

treatment,  264 
of  vas  deferens,  263 
of  vesiculee  seminales,  263 
of  wrist,  748 
papillomatosa  cutis,  250 
pathology  of  the  blood  in,  83 
urethras,  261 
vera  cutis,  250 
verrucosa  cutis,  250 
Tuberculous  disease  of  bone,  686.     See  Bone, 
tuberculous  disease  of. 
empyema,  255 

treatment,  255 
lymphadenitis,  251 

diagnosis,  252 

pathological  anatomy,  252 

symptoms,  252 

treatment,  252 
meningitis,  254 
nodes,  250 
osteomyelitis,  687 
periostitis,  687 
peri-urethritis,  261 
pleurisy,  255 

treatment,  255 
pus,  66 
pyelitis,  266 
Tubular  aneurysm,  914 
lymphangitis,  928 

symptoms,  929 

treatment,  929 
Tubulocysts,  502 
Tubulodermoids,  499 
Tumor,  51 
Tumors,  466 
adrenal,  487 
bony,  475 
cartilaginous,  475 
cerebellar,  symptoms,  817 
congenital  sacrococcygeal,  839 
connective-tissue,  471 
difference  between   benign    and    malignant, 

478 
epithelial,  489 
fatty,  473 

influence  of  environment  on,  466 
innocent,  characters  of,  466 

coexistence   of  two   genera    in    the   same 
person,  470 
intracranial,  813 
lvmph-gland,  infection  of,  471 
malignant,  characters  of,  466 

dissemination  of,  471 
nerve-,  883 


964 


INDEX. 


Tumors  of  bone,  699 
(if  brain,  813 
of  knee,  740 
of  muscle,  773 
of  scalp,  786 

malignant,  789 
of  spinal  canal,  856 
of  spinal  column,  855 
diagnosis,  855 
symptoms,  855 
treatment,  856 
of  spinal  cord,  856 
symptoms,  856 
treatment,  856 
of  spleen,  926 

primary,  of  lymph-glands,  935 
tooth,  476 
Tunica  adventitia,  897 
intima,  896 
media,  897 
Turpentine  in  aseptic  surgery,  278 

stupe,  425 
Typhoid  fever,  periostitis  and  ostitis  after,  675 
treatment  of,  675 

Ulcer,  74 
callous,  77 
erethistic,  77 
fungous,  77 
hemorrhagic,  77 
inflamed,  77 
of  scalp,  786 
phagedenic,  78 
rodent,  496 
torpid,  77 
treatment  of,  78 
varicose,  76 
Ulna,  dislocation  of,  635 
lower  extremity,  636 
upper  extremity,  636 
excision  and  resection  of,  391 
fracture  of  shaft  of,  562 
Ulnar  artery,  ligature  of,  324 
nerve  at  elbow,  injury  of,  890 
at  wrist,  injury  of,  890 
in  hand,  injuries  of,  890 
injury  of,  890 
Umbilicus,  gangrene  of,  235 
Union  of  fracture,  delayed,  523 
faulty,  523 
fibrous,  524 
ligamentous,  524 
vicious,  523 
Ununited  fracture,  resection  of  bones  for,  382 

wiring  of,  385 
Upper  extremity,   spiral  reversed  bandage  of, 

410 
Urethra,  male,  tuberculosis  of,  261 

sterilization  of,  294 
Urethral  rheumatism,  712 

synovitis,  712 
Urine-serum-agar,  33 
Uterine  fibroid,  481 
Uterus,  myomata  of,  481 

Vagina,  sterilization  of,  295 
Varices,  909 
Varicose  ulcer,  76 

treatment,  78 
veins,  909 

treatment,  910 
Varix,  arterial,  911 
Vas  deferens,  tuberculosis  of,  263 


Vascular  tumors  of  scalp,  789 
Veins,  anatomy  of,  905 

repair  of,  901 

rupture  of,  900 

varicose,  909 

wounds  of,  899 
Velpeau's  bandage,  416 
Venesection,  424 

in  inflammation,  52 
Venous  hematoma,  900 

hemorrhage,  897 
Vermale's  amputation  of  thigh,  359 
Verneuil's  method  of  rhinoplasty,  401 
Verruca  necrogenica,  250.     See  also  Anatomi- 
cal tubercle. 
Vertebrae,  acute  osteomyelitis  of,  840 

erosion  of,  by  aneurysm,  854 
Vertebral  artery,  ligature  of,  321 
Vesiculae  seminales,  tuberculosis  of,  263 
Vesuvin,  27 
Vibrion  septique,  38 
Vicious  union  of  fracture,  523 
Vienna  mixture,  444 
Villous  papillomata,  489 

Virchow's  doctrine  of  tissue-prototypes,  471 
Visual  area,  794 

speech-area,  794 
Volk/nann's  sliding  rest,  581 
Von  Langenbeck's  excision  of  hip-joint,  370 
of  shoulder-joint,  364,  365 
of  wrist,  370 

method  of  rhinoplasty,  400,  402 

resection  of  maxilla  for  polyps,  386 
Vulva,  noma  of,  235 

Wagner's  excision  of  second  division  of  tri- 
facial, 875 
Wandering  erysipelas,  175 
Wart  horns,  491 
Warts,  489 

Washing  of  stomach,  436 
Water,  sterilization  of,  279 
Weaver's  bottom,  783 

Weber's  operation  for  repair  of  elliptical  de- 
fects, 398 
Weeping-sinew,  775 
Wen,  786 
Wens,  786 

fungating,  496 
Wet  cold,  local  application  of,  426 

cupping,  434 
White  swelling,  713 

of  elbow,  746 
Whitlow,  thecal,  773 
symptoms,  774 
treatment,  775 
Whitman's  brace  for  flat-foot,  758 
Wiring  of  ununited  fractures,  383 
Woolsorters'  disease,  197.     See  Anthrax. 

fever,  aseptic,  142 
Wound-suture,  aseptic,  296 
Wounds,  88 

accident,  disinfection  of,  295 

arrest  of  hemorrhage  from,  95 

classification  of,  88 

cleansing  of,  97 

clinical  course  of,  89 

coaptation  of,  99 

constitutional  reactions  to,  140 

contused,  88 
treatment,  98 

disinfection  of,  97 
carbolic  acid  in,  97 


INDEX. 


965 


Wounds,  drainage  of,  100 
dressing  of,  102 
gunshot,  of  head,  805 
healing  of,  89 
hemorrhage  from,  89 
histological  considerations  of,  91 
lacerated,  88 
of  arteries,  899 

repair  of,  136 
of  heart,  894 
of  joints,  600 
of  lymphatic  vessels,  927 
of  muscles,  768 

treatment,  768 
of  nerves,  862 
of  pericardium,  894 
of  skin,  repair  of,  125 
of  tendons,  769 

diagnosis,  769 

treatment,  769 
of  thoracic  duct,  927 
of  veins,  899 
pain  of,  89 
penetrating,  88 
perforating,  88 
poisoned,  105 

symptoms,  106 

treatment,  107 
postoperative  treatment,  299 
redressing  of,  103 
secondary  suturing  of,  99 
suturing  of,  99 
symptoms,  88 
treatment,  95 
Wrist,  amputation  of,  342 
diseases  of,  748 


Wrist,  diseases  of,  mechanical  treatment,  749 
dislocation  of,  640 
excision  of,  368 
fracture  of,  571 
causation,  640 
diagnosis,  641 
frequency,  640 
individual  bones  of,  641 
pathology,  640 
prognosis,  641 
symptoms,  640 
treatment,  641 
rheumatism  of,  acute,  748 

gonorrheal.  748 
tubercular  inflammation  of,  748 
Writers'  cramp,  772 
Wry-neck,     spasmodic,     surgical     treatment, 

881 
Wuth,  190 

Wyeth's  amputation  of  arm,  345 
at  shoulder-joint,  347 
of  thigh,  360 
bloodless  amputation  at  hip,  363 

X-RAY  burns,  114 

X-rays  in  diagnosis  of  dislocations,  608 

prevention  of,  116 

symptoms  of,  115 

treatment  of,  116 

Y-LIGAMENT,  660 

Ziehl-Nielsen  method  of  staining  tubercle 

bacilli,  35 
Ziehl's   method   of    staining    tubercle    bacilli, 

35 


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plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches;  with  over  ioo  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
Dorland,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  800  pages,  bound  in  full  flexible  leather. 
Price,  $4.50  net ;  with  thumb  index,  $5.00  net. 

Gives  a  Maximum  Amount  of  Matter  in  a  Minimum  Space,  and  at  the  Lowest 

Possible  Cost 

TWO   LARGE   EDITIONS    IN   LESS   THAN    EIGHT   MONTHS 

The  immediate  success  of  this  work  is  due  to  the  special  features  that  distin- 
guish it  from  other  books  of  its  kind.  It  gives  a  maximum  of  matter  in  a  mini- 
mum space  and  at  the  lowest  possible  cost.  Though  it  is  practically  unabridged, 
yet  by  the  use  of  thin  bible  paper  and  flexible  morocco  binding  it  is  only  1  $4 
inches  thick.  The  result  is  a  truly  luxurious  specimen  of  book-making.  In  this 
new  edition  the  book  has  been  thoroughly  revised,  and  upward  of  one  hundred 
important  new  terms  that  have  appeared  in  recent  medical  literature  have  been 
added,  thus  bringing  the  book  absolutely  up  to  date.  The  book  contains  hun- 
dreds of  terms  not  to  be  found  in  any  other  dictionary,  over  100  original  tables, 
and  many  handsome  illustrations,  including  24  colored  plates. 


PERSONAL    OPINIONS 


Howard  A.  Kelly,  M.  D., 

Professor  of  Gynecology,  Johns  Hopkins  University,  Baltimore. 

"  Dr.  Dorland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 

Roswell  Park,  M.  D., 

Professor  of  Principles  and  Practice  of  Surgery  and  of  Clinical  Surgery,  University  of 
Buffalo. 

"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  within  rela- 
tively small  space.  I  find  nothing  to  criticize,  very  much  to  commend,  and  was  interested  in 
finding  some  of  the  new  words  which  are  not  in  other  recent  dictionaries." 


THE  PRACTICE    OF  MEDIC  EXE. 


Saunders' 
American  Year-Book 


The  American  Year=Book  of  Medicine  and  Surgery  for  1902.     A 

Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  foreign  authors  and  inves- 
tigators. Arranged  with  critical  editorial  comments  by  eminent  Amer- 
ican specialists,  under  the  editorial  charge  of  George  M.  Gould,  M.  D. 
Year-Book  of  1902  in  two  volumes — Vol.  I.,  including  General  Medicine  ; 
Vol.  II.,  General  Surgery.  Per  volume:  Cloth,  $3.00  net;  Half  Mo- 
rocco, $3.75  net.     Sold  by  Subscription. 

EQUIVALENT  TO  A  POST-GRADUATE  COURSE 

The  contents  of  these  volumes,  critically  selected  from  leading  journals,  mono- 
graphs, and  text-books,  is  much  more  than  a  compilation  of  data.  The  extracts 
are  carefully  edited  and  commented  upon  by  eminent  specialists,  the  reader  thus 
obtaining  not  only  a  yearly  digest  of  scientific  progress  and  authoritative  opinion 
in  all  branches  of  medicine  and  surgery,  but  also  the  invaluable  annotations  and 
criticisms  of  the  Editors,  all  leaders  in  their  several  specialties.  The  work,  more- 
over, is  not  lacking  in  its  illustrative  feature  ;  for,  besides  a  large  number  of 
text-cuts,  the  volumes  contain  several  full-page  plates  of  exceptional  merit. 


OPINIONS  OF  THE   MEDICAL   PRESS 


The  Lancet,  London 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted  to 
experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  commen- 
taries and  expositions  .   .  .  proceeding  from  writers  fully  qualified  to  perform  these  tasks." 

Boston  Medical  and  Surgical  Journal 

"  An  immense  deal  of  work  has  been  put  into  it.  and  the  editor,  seconded  by  a  large  corps 
of  competent  collaborators,  has  succeeded  in  satisfactorily  covering  the  extended  field  which 
he  has  set  himself  the  task  of  cultivating.  It  is  a  very  desirable  book  for  the  general  practi- 
tioner." 

British  Medical  Journal 

"  It  is  unrivaled  among  similar  publications  in  the  English  language." 


SAUNDERS'    BOOKS   ON 


Gould  and  Pyle's 
Curiosities  of  Medicine 


Anomalies  and  Curiosities  of  Medicine.  By  George  M.Gould, 
M.  D.,  and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of 
rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an 
exhaustive  research  of  medical  literature  from  its  origin  to  the  present 
day,  abstracted,  classified,  annotated,  and  indexed.  Handsome  octavo 
volume  of  968  pages  ;   295  engravings  and  12  full-page  plates. 

Popular  Edition :  Cloth,  $3.00  net ;  Sheep  or  Half  Morocco.  $4.00  net. 

This  book  is  not  an  illogic  smattering  of  curious  facts,  but  is  a  complete  ency- 
clopedia of  the  whole  subject.  Several  years  of  exhaustive  research  have  been 
spent  by  the  authors  in  the  great  medical  libraries  of  the  United  States  and 
Europe  in  collecting  the  material  for  the  work.  Medical  literature  of  all  ages 
and  all  languages  has  been  carefully  searched,  as  a  glance  at  the  Bibliographic 
Index  will  show.  As  a  complete  and  authoritative  Book  of  Reference  it  will  be 
of  value  not  only  to  members  of  the  medical  profession,  but  to  all  persons  inter- 
ested in  general  scientific,  sociologic,  and  medicolegal  topics  ;  in  fact,  the  absence 
of  any  complete  work  upon  the  subject  makes  this  volume  one  of  the  most  impor- 
tant literary  innovations  of  the  day. 


OPINIONS  OF  THE   MEDICAL  PRESS 


The  Lancet,  London 

"  The  book  is  a  monument  of  untiring  energy,  keen  discrimination,  and  erudition.  *  *  * 
We  heartily  recommend  it  to  the  profession." 

New  York  Medical  Journal 

"  We  would  gladly  exchange  a  multitude  of  the  relatively  useless  works,  which  but  encum- 
ber all  branches  of  medicine,  for  one  so  comprehensive,  so  exhaustive,  so  able,  and  so  remark- 
able in  its  field  as  this." 

University  Medical  Magazine 

"  Drs.  Gould  and  Pyle  have  evolved  in  this  volume  a  monumental  work  of  industry  and 
patience  and  skill,  and  have  contributed  a  priceless  addition  to  the  medical  literature  of  the 
world." 


THE   PRACTICE    OF  MEDICINE 


Anders' 
Practice  of  Medicine 

Fifth  Revised  Edition 


A  Text=Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo,  1297  pages,  fully  illustrated.  Cloth,  $5.50  net;  Sheep 
or  Half  Morocco,  $6.50  net. 

FIVE  LARGE  EDITIONS  IN  FOUR  YEARS 

The  success  of  this  work  as  a  text-book  and  as  a  practical  guide  for  physi- 
cians has  been  truly  phenomenal.  Five  large  editions  have  been  called  for  in 
less  than  four  years.  The  rapid  exhaustion  of  each  edition  has  made  it  possible 
to  keep  the  book  absolutely  abreast  of  the  times,  so  that  Anders'  Practice  has 
become  justly  celebrated  as  the  most  up-to-date  work  on  practice.  In  this 
edition  extensive  changes  have  been  made  in  connection  with  the  large  group 
of  Infectious  Diseases.  The  etiology  and  mode  of  transmission  of  Malaria  and 
of  Yellow  Fever  have  been  almost  entirely  rewritten.  Certain  affections  of  grow- 
ing importance,  as  Diphtheritic  Dysentery  and  Parasitic  Hemoptysis,  have  been 
recast  and  more  fully  discussed.  The  new  articles  include  Fatty  Infiltration 
of  the  Heart,  Streptococcus  Pneumonia,  and  Acute  Diffuse  Interstitial  Nephritis. 


PERSONAL  OPINIONS 


James  C.  Wilson,  M.  D., 

Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medicine,  Jefferson  Medical  College 

Philadelphia. 
"  It    is   an   excellent    book — concise,  comprehensive,   thorough,  and    up-to-date.     It   is   a 
credit  to  you;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 

A.  C.  Cowperthwait,  M.  D., 

President  Illinois  Homeopathic  Medical  Association. 

"  I  consider  Dr.  Anders'  book  not  only  the  best  late  work  on  Medical  Practice,  but  by  far 
the  best  that  has  ever  been  published.  It  is  concise,  systematic,  thorough,  and  fully  up-to-date 
in  everything.     I  consider  it  a  great  credit  to  both  the  author  and  the  publishers." 

George  Roe  Lockwood,  M.  D., 

Attending  Physician  to  the  Belleviie  Hospital,  New   York. 

"  I  have  read  several  of  the  important  chapters  carefully,  and  am  very  much  pleased  with 
the  work.  It  is  thoroughly  up-to-date,  well  expressed,  and  shows  evidence  of  clinical  expe- 
rience." 


SAUNDERS'    BOOKS   ON 


AMERICAN   EDITION 

NOTHNAGEL'S  PRACTICE 

UNDER    THE    EDITORIAL    SUPERVISION    OK 

ALFRED    STENGEL,  M.D. 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Visiting 
Physician  to  the  Pennsylvania  Hospital. 


BEST  IN 
EXISTENCE 


It  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal  Medicine ;  and 
of  all  the  German  works  on  this  subject,  Nothnagel's  "  Specielle  Pathologie  und  Therapie" 
is  conceded  by  scholars  to  be  without  question  the  best  Practice 
of  Medicine  in  existence.  So  necessary  is  this  book  in  the  study 
of  Internal  Medicine  that  it  comes  largely  to  this  country  in  the 
original  German.  In  view  of  these  facts,  Messrs.  W.  B.Saunders  & 
Company  have  arranged  with  the  publishers  of  the  German  edition 
to  issue  at  once  an  authorized  American  edition  of  this  great  Practice  of  Medicine. 

For  the  present  a  set  of  ten  volumes,  selected  with  especial  thought  of  the  needs  of  the 
practising  physician,  will  be  published.  These  volumes  will  con- 
tain the  real  essence  of  the  entire  work,  and  the  purchaser  will 
therefore  obtain,  at  less  than  half  the  cost,  the  cream  of  the  orig- 
inal. Later  the  special  and  more  strictly  scientific  volumes  will 
be  offered  from  time  to  time. 


FOR  THE 
PRACTITIONER 


The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both  English  and 
German,  and  each  volume  will  be  edited  by  a  prominent  specialist.  It  will  thus  be  brought 
thoroughly  up  to  date,  and  the  American  edition  will  be  more  than  a  mere  translation  ;  for, 
in  addition  to  the  matter  contained  in  the  original,  it  will  represent 


PROMINENT 
SPECIALISTS 


the  very  latest  views  of  the  leading  American  and  English  special- 
ists in  the  various  departments  of  Internal  Medicine.  Moreover, 
as  each  volume  will  be  revised  to  the  date  of  its  publication  by  the 
eminent  editor,  the  objection  that  has  heretofore  existed  to  treatises 
published  in  a  number  of  volumes  will  be  obviated,  since  the  subscriber  will  receive  the  com- 
pleted work  while  the  earlier  volumes  are  still  fresh.  The  American  publication  of  the  entire 
work  is  under  the  editorial  supervision  of  Dr.  Alfred  Stengel,  who  has  selected  the  subjects 
for  the  American  Edition,  and  has  chosen  the  editors  of  the  different  volumes. 

The  usual  method  of  publishers  when  issuing  a  publication  of 
this  kind  has  been  to  compel  physicians  to  take  the  entire  work. 
This  seems  to  us  in  many  cases  to  be  undesirable.  Therefore,  in 
purchasing  this  Practice  physicians  will  be  given  the  opportunity 
of  subscribing  for  it  in  entirety  ;  but  any  single  volume  or  any 
number  of  volumes,  each  complete  in  itself,  may  be  obtained  by  those  who  do  not  desire  the 
complete  series.  This  latter  method  offers  to  the  purchaser  many  advantages  which  will  be 
appreciated  by  those  who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

SEE  NEXT  TWO  PAGES  FOR  LIST 


VOLUMES  SOLD 
SEPARATELY 


PRACTICE    OF  MEDICINE. 


AMERICAN   EDITION 

NOTHNAGEL'S  PRACTICE 

VOLUMES   NOW   READY 


Typhoid  and  Typhus  Fevers 

By  Dr.  H.  Curschmaxx,  Professor  of  Medicine  in  Leipsic.  The  entire 
volume  edited,  with  additions,  by  William  Osler,  M.  D.,  F.  R.  C.  P., 
Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  Univer- 
sity, Baltimore.  Octavo,  646  pages,  illustrated.  Cloth,  $5.00  net  ;  Half 
Morocco,  $6.00  net. 

"Under  the  editorial  supervision  of  Dr.  Osier,  the  original  German  work,  excellent 
though  it  is,  has  been  much  improved,  greatly  enlarged,  and  enhanced  in  value,  espe- 
cially to  American  readers.  .  .  .  The  monograph  on  typhoid  fever  is  the  best  exponent 
of  the  knowledge  that  we  have  in  regard  to  this  disease  that  is  to  be  had  in  any  lan- 
guage."— Journal  of  the  American  Medical  Association. 

Smallpox  (including  Vaccination),  Varicella,  Cholera  Asiatica, 
Cholera  Nostras,  Erysipelas,  Erysipeloid,  Pertussis,  and 
Hay  Fever 

By  Dr.  H.  Immermaxx,  of  Basle;  Dr.  Th.  von  Jurgexsex,  of  Tubin- 
gen ;  Dr.  C.  Liebermeister,  of  Tubingen  ;  Dr.  H.  Lexhartz,  of  Ham- 
burg ;  and  Dr.  G.  Sticker,  of  Giessen.  The  entire  volume  edited,  with 
additions,  by  Sir  J.  W.  Moore,  M.  D.,  F.  R.  C.  P.  I.,  Professor  of  Prac- 
tice, Royal  College  of  Surgeons,  Ireland.  Octavo,  682  pages,  illustrated. 
Cloth,  $5.00  net ;   Half  Morocco,  $6.00  net. 

"  Dr.  Immermann's  vindication  of  vaccination  in  the  prophylaxis  of  smallpox  will  be 
read  with  peculiar  interest  at  the  present  time,  since  it  is  probably  the  most  complete 
and  unassailable  indictment  of  the  propaganda  of  antivaccination  fanatics  which  has  ever 
been  published." — The  London  Lancet. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  William  P.  Northrup,  M.  D.,  of  New  York,  and  Dr.  Th.  von 
Jurgexsex,  of  Tubingen.  The  entire  volume  edited,  with  additions,  by 
William  P.  Northrup,  M.  D.,  Professor  of  Pediatrics,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  Octavo,  672  pages,  illus- 
trated, including  24  full-page  plates,  3  in  colors.  Cloth,  S5.00  net  ;  Half 
Morocco,  $6.00  net. 

"  The  author  is  to  be  congratulated  on  the  exhaustive  and  practical  manner  in  which 
he  presents  the  subject.  .  .  .  The  articles  on  measles,  scarlet  fever,  and  German  measles 
are  exhaustive  treatises,  with  numerous  additions  by  the  American  editor." — Journal 
of  the  American  Medical  Association. 

Diseases  of  the  Bronchi,  Diseases  of  the  Pleura,  and  Pneu- 
monia 

By  Dr.  F.  A.  Hoffmaxx,  of  Leipsic  ;  Dr.  O.  Rosexbach,  of  Berlin  ;  and 
Dr.  F.  Aufrecht,  of  Magdeburg.  The  entire  volume  edited,  with  additions, 
by  Johx  H.  Musser,  M.  D.,  Professor  of  Clinical  Medicine,  University  of 
Pennsylvania.  Octavo,  1029  pages,  illustrated,  including  7  full-page  colored 
lithographic  plates.      Cloth,  #5.00  net  ;   Half  Morocco,  $6.00  net. 

The  author  has  made  numerous  valuable  additions,  so  that  the  American  edition 
represents  the  present  state  of  our  knowledge  on  the  subjects  under  discussion.  Much 
new  matter  has  been  incorporated  into  the  section  on  pneumonia,  and  references  to  the 
work  of  Morse  on  the  leukocytes  in  pleurisy,  to  that  of  Williams  and  others  on  X-ray 
diagnosis,  and  to  the  Litten  phenomenon,  are  included. 


io  SAUNDERS'    BOOKS   ON 

AMERICAN    EDITION 

NOTHNAGEL'S  PRACTICE 

VOLUMES  NOW  READY  AND  IN  PRESS 


Diseases  of  the  Liver,  Pancreas,  and  Suprarenals 

By  Drs.  H.  Quincke  and  G.  Hoppe-Seyler,  of  Kiel  ;  Dr.  L.  Oser,  of 
Vienna  ;  and  Dr.  E.  Neusser,  of  Vienna.  The  entire  volume  edited,  with 
additions,  by  Frederick  A.  Packard,  M.  D.,  Physician  to  the  Pennsyl- 
vania and  to  the  Children's  Hospitals,  Philadelphia  ;  and  Reginald  H.  Fitz, 
A.  M.,  M.  D.,  Hersey  Professor  of  the  Theory  and  Practice  of  Physic,  Har- 
vard University.  Octavo  of  about  850  pages,  illustrated.  Cloth,  #5.00  net ; 
Half  Morocco,  $6.00  net. 

It  has  been  the  aim  of  the  authors  and  editor  of  this  work  to  describe  the  present  con- 
dition of  our  knowledge  on  the  subjects,  to  point  out  where  it  is  deficient,  and  to  stimu- 
late to  new  work.     The  work  will  be  found  practical  in  every  particular. 

Diseases  of  the  Stomach 

By  Dr.  F.  Riegel,  of  Giessen.  Edited,  with  additions,  by  Charles 
G.  Stockton,  M.  D.,  Professor  of  Medicine,  University  of  Buffalo.  Hand- 
some octavo  of  800  pages,  with  29  text-cuts  and  6  full-page  plates. 

Diseases  of  the  Intestines  and  Peritoneum 

By  Dr.  Hermann  Nothnagel,  of  Vienna.  The  entire  volume  edited, 
with  additions,  by  Humphrey  D.  Rolleston,  M.  D.,  F.  R.  C.  P.,  Physi- 
cian to  and  Lecturer  on  Pathology  at  St.  George's  Hospital,  London.  Hand- 
some octavo  of  800  pages,  finely  illustrated. 

Influenza,  Dengue,  Malarial  Diseases 

By  Dr.  O.  Leichtenstern,  of  Cologne,  and  Dr.  J.  Mannaberg,  of 
Vienna.  The  entire  volume  edited,  with  additions,  by  Ronald  Ross, 
F.  R.  C.  S.,  Eng.,  D.  P.  H.,  F.  R.  S.,  Major,  Indian  Medical  Service,  retired  ; 
Walter  Myers  Lecturer,  Liverpool  School  of  Tropical  Medicine,  Liverpool. 
Handsome  octavo  of  700  pages,  with  7  full-page  lithographic  plates  in 
colors. 

Anemia,    Leukemia,    Pseudoleukemia,    Hemoglobinemia,    and 
Chlorosis 

By  Dr.  P.  Ehrlich,  of  Frankfort-on-the-Main  ;  Dr.  A.  Lazarus,  of 
Charlottenburg  ;  Dr.  Felix  Pinkus,  of  Berlin  ;  and  Dr.  K.  von  Noorden, 
of  Frankfort-on-the-Main.  The  entire  volume  edited,  with  additions,  by 
Alfred  Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University  of 
Pennsylvania.  Handsome  octavo  of  750  pages,  with  5  full-page  lithographs 
in  colors. 

Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

By  Dr.  G.  Cornet,  of  Berlin.  Handsome  octavo  of  700  pages.  The 
editor  of  this  volume  will  be  announced  later. 

EACH  VOLUME  IS  COMPLETE  IN  ITSELF  AND  IS  SOLD  SEPARATELY 


MATERIA   MEDICA   AND    THERAPEUTICS 

Stevens' 
Modern  Therapeutics 


A  Text-Book  of  Modern  Therapeutics.  By  A.  A.  Stevens,  A.  M., 
M.  D.,  Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsyl- 
vania.    Handsome  octavo  of  about  600  pages.     Cloth,  $0.00  net. 

THIRD   EDITION,  ENTIRELY  REWRITTEN  AND  GREATLY  ENLARGED 

Since  the  appearance  of  the  last  edition  of  this  book  such  rapid  advances 
have  been  made  in  Materia  Medica,  Therapeutics,  and  the  allied  sciences  that 
the  author  felt  it  imperative  to  rewrite  the  work  entirely.  All  the  newer  reme- 
dies that  have  won  approval  by  recognized  authorities  have  been  incorporated, 
bringing  the  book  absolutely  down  to  date.  It  is  based  on  the  latest  edition  of 
the  Pharmacopceia,  and  includes  the  following  sections  :  Physiologic  Action  of 
Drugs  ;  Drugs  ;  Remedial  Measures  other  than  Drugs  ;  Applied  Therapeutics  ; 
Incompatibility  in  Prescriptions  ;  Table  of  Doses  ;  Index  of  Drugs  ;  and  Index 
of  Diseases  ;  the  treatment  being  elucidated  by  more  than  two  hundred  formulas. 


OPINIONS  OF  THE  MEDICAL  PRESS 


New  York  Medical  Journal 

"  The  work  which  Dr.  Stevens  has  written  is  far  superior  to  most  of  its  class;  in  fact,  it  is 
very  good.  .  .  .  The  book  is  reliable  and  accurate." 

University  Medical  Magazine 

"The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work  .  .  . 
and  it  will  be  found  a  reliable  guide  and  sufficiently  comprehensive  for  the  physician  in 
practice." 

Bristol  Medico-Chirurgical  Journal,  Bristol 

"This  addition  to  the  numerous  works  on  Therapeutics  is  distinctly  a  good  one.  ...  It 
is  to  be  recommended  as  being  systematic,  clear,  concise,  very  fairly  up  to  date,  and  carefully 
indexed." 


SAUNDERS'    BOOKS   ON 


Sollmann's 
Text-Book  of  Pharmacology 

Including  Therapeutics,  Materia  Medica,  Pharmacy, 
Prescription-writing,  Toxicology,  etc. 


A  Text=Book  of  Pharmacology  :  including  Therapeutics,  Mate- 
ria Medica,  Pharmacy,  Prescription-writing,  Toxicology,  etc.  By 
Torald  Sollmann,  M.  D.,  Assistant  Professor  of  Pharmacology  and 
Materia  Medica,  Medical  Department  of  Western  Reserve  University, 
Cleveland,  Ohio.  Handsome  octavo  volume  of  894  pages,  fully  illus- 
trated.    Cloth,  $3.75  net. 

A  NEW  WORK— JUST  ISSUED 

This  work  aims  to  furnish,  in  a  manner  suited  for  reference  and  study,  a 
scientific  discussion  and  definite  conception  of  the  action  of  drugs,  as  well  as 
their  derivation,  composition,  strength,  and  dose.  The  author  bases  the  study 
of  therapeutics  on  a  systematic  knowledge  of  the  nature  and  properties  of  drugs, 
and  thus  brings  out  forcibly  the  intimate  relation  between  pharmacology  and 
practical  medicine.  Practitioners  and  students  will  find  the  work  an  admirable 
guide  in  that  most  important  part  of  their  equipment,  namely,  how  to  use  drugs 
accurately  and  efficaciously. 


PERSONAL  AND   PRESS  OPINIONS 


J.  F.  Fotheringham,  M.  D„ 

Professor  of  Therapeutics  and  Theory  and  Practice  of  Prescribing,  Trinity  Medical  College, 
Toronto. 

"The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scientific  a 
manner  by  any  other  text  I  have  read  on  the  subjects  embraced." — October  jo,  iqoi. 

British  Medical  Journal 

"  The  book  is  well  worthy  the  attention  of  all  who  are  interested  in  the  pharmacological 
and  physiological  side  of  therapeutics." 

Medical  News,  New  York 

"  It  has  rarely  been  our  fortune  to  review  so  clear,  concise,  and  well-arranged  a  work.  .  .  . 
The  pharmacist  will  find  welcome  information  which  other  books  on  the  same  subject  usually 
neglect.     We  consider  the  book  one  of  the  best." 


MATERIA    MEDIC  A    AND    THERAPEUTICS.  13 

Butler's  Materia  Medica, 

Therapeutics,  and  Pharmacology 


A  Text=Book  of  Materia  Medica,  Therapeutics,  and  Pharma= 
cology.  By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  of  Materia 
Medica  and  of  Clinical  Medicine,  College  of  Physicians  and  Surgeons, 
Chicago.  Octavo,  896  pages,  illustrated.  Cloth,  $4.00  net ;  Sheep  or 
Half  Morocco,  $5.00  net. 

FOURTH   EDITION,  REVISED   AND   ENLARGED 

In  this  new  edition  the  work  has  been  thoroughly  revised  and  remodeled, 
bringing  it  absolutely  down  to  date.  The  pharmacology  and  therapeutics  of 
each  drug  have  been  thoroughly  revised,  incorporating  all  the  recent  advances 
made  in  pharmacodynamics.  In  view  of  a  larger  experience,  resulting  in  more 
definite  conclusions,  numerous  changes  have  been  made  in  the  expressions  of 
opinion  regarding  the  utility  of  certain  drugs,  notably  the  newer  synthetics.  The 
chapters  on  Organo-therapy,  Serum-therapy,  and  cognate  subjects  have  been 
enlarged  and  carefully  revised,  so  that  they  now  portray  the  present  knowledge 
on  these  subjects.  But  perhaps  the  most  important  addition  is  the  chapter 
devoted  to  the  newer  theories  of  electrolytic  dissociation  and  its  relation  to  the 
topic  of  pharmacotherapy,  and  the  relevant  discussion  added  of  the  simpler 
relations  of  chemical  structure  of  drug-action. 


OPINIONS  OF  THE   MEDICAL  PRESS 


Journal  of  the  American  Medical  Association 

"Taken  as  a  whole,  the  book  may  be  considered  as  one  of  the  most  satisfactory  single- 
volume  works  on  materia  medica  on  the  market." 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the  com- 
pleteness of  the  text,  and  the  student  or  general  reader  is  given  the  benefit  of  latest  advices 
bearing  upon  the  value  of  drugs  and  remedies  considered." 

Buffalo  Medical  Journal 

"  It  brings  before  the  student  a  clear,  concise,  and  truthful  account  of  each  drug,  and  pre- 
sents it  in  a  manner  calculated  to  impress  the  memory." 


i4  SAUNDERS'   BOOKS    ON 

Thornton's   Dose-Book 

Dose=Book  and  Manual  of  Prescription-Writing.  By  E.  Q.  Thorn- 
ton, M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College, 
Phila.  Post-octavo,  362  pages,  illustrated.  Flexible-  Leather,  $2.00 
net. 

Second  Edition,  Revised  and  Enlarged 

In  the  new  edition  of  this  work,  intended  for  the  student  and  practitioner, 
additions  have  been  made  to  the  chapters  on  "Prescription-Writing"  and 
"Incompatibilities,"  and  references  have  been  introduced  in  the  text  to  the 
newer  curative  sera,  organic  extracts,  synthetic  compounds,  and  vegetable  drugs. 
To  the  Appendix,  chapters  upon  Synonyms  and  Poisons  and  their  antidotes 
have  been  added,  thus  increasing  its  value  as  a  book  of  reference. 

C.  H.  Miller.  M.  D., 

Professor  of  Pharmacology \  Northwestern  University  Medical  School,  Chicago. 

"  I  will  be  able  to  make  considerable  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-writing,  and  it  will  afford  me  much  pleasure  to  recommend 
the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text-books." 


American  Text-Book  of 
Applied  Therapeutics 

American  Text-Book  of  Applied  Therapeutics.  Edited  by  James 
C.  Wilson,  M.  D.,  Professor  of  Practice  of  Medicine  and  of  Clinical 
Medicine,  Jefferson  Medical  College,  Philadelphia.  Handsome  imperial 
octavo  volume  of  1326  pages.  Illustrated.  Cloth,  $7.00  net;  Sheep 
or  Half  Morocco,  $8.00  net. 

For  Student  and  Practitioner 

Written  for  both  the  student  and  practitioner,  the  aim  of  this  work  is  to 
facilitate  the  application  of  knowledge  to  the  prevention,  cure,  and  alleviation 
of  disease.  The  endeavor  throughout  has  been  to  conform  to  the  title  of  the 
book — "  Applied  Therapeutics  " — to  indicate  the  course  of  treatment  to  be  pur- 
sued at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  have  been  used  at 
one  time  or  another.      The  work  will  be  found  accurate  and  trustworthy. 

Buffalo  Medical  Journal 

"  It  is  one  of  the  most  complete  books  of  reference  that  has  been  presented  to  the  profes- 
sion on  medicine  in  a  long  period  of  time ;  and  never  before  have  we  had  one  that  undertook 
to  cover  the  field  in  this  manner." 


PRACTICE,   MATERIA    MEDIC  A,   Etc.  15 

The  American  Pocket  Medical  Dictionary.     Third  Edition,  Revised 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  Newman  Dor- 
land,  M.  D.,  Assistant  Obstetrician  to  the  Hospital  of  the  University  of  Pennsylvania. 
Containing  the  pronunciation  and  definition  of  the  principal  words  used  in  n  edicine 
and  kindred  sciences,  with  64  extensive  tables.  Flexible  leather,  with  gold  edges, 
#1.00  net ;  with  thumb  index,  #1.25  net. 

*'  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  Holland,  M.  D.,  Dean  of  the 
Jefferson  Medical  College,  Philadelphia. 

Vierordt's    Medical    Diagnosis.      Fourth  Edition,  Revised 

Medical  Diagnosis.  By  Dr  Oswald  Vierordt,  Professor  of  Medicine,  Univer- 
sity of  Heidelberg.  Translated  from  the  fifth  enlarged  German  edition  by  Francis 
H.  Stuart,  A.  M.,  M.  D.  Octavo,  603  pages,  104  wood  cuts.  Cloth,  $4.00  net; 
Sheep  or  Half  Morocco,  $5.00  net. 

"  Has  been  recognized  as  a  practical  work  of  the  highest  value.  It  may  he  considered  indispensable 
both  to  students  and  practitioners." — F.  Minot,  M.  D.,  late  Professor  of  Theory  anil  Practice  in 
Harvard  University. 

Cohen   and    Eshner's   Diagnosis.      Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  Lecturer  on  Clinical  Medi- 
cine, Jefferson  Medical  College,  Phila.  ;  and  A.  A.  Eshner,  M.  D.,  Professor  of  Clin- 
ical Medicine,  Philadelphia  Polyclinic.  Post-octavo,  382  pages ;  55  illustrations. 
Cloth,  $1. 00  net.      In  Saunders1   Question-  Compcnd  Series. 

"Concise  in  the  treatment  of  subject,  terse  in  expression  of  fact." — American  Journal  of  the 
Medical  Sciences. 

Morris'  Materia  Medica  and  Therapeutics.     Fifth  Revised  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription-Writing. 
By  Henry  Morris,  M.  D.,  late  Demonstrator  of  Therapeutics.  Jefferson  Medical 
College,  Phila.  Post-octavo,  250  pages.  Cloth,  $1.00  net.  ///  Saunders1  Question- 
Compend  Series. 

"Cannot  fail  to  impress  the  mind  and  instinct  in  a  lasting  manner." — Buffalo  Medical  Journal. 

Sayre's  Practice  of  Pharmacy.     Second  Edition,  Revised 

Essentials  of  the  Practice  of  Pharmacy.  By  Lucius  E.  Sayre,  M.  D.,  Pro- 
fessor of  Pharmacy,  University  of  Kansas.  Post-octavo,  200  pages.  Cloth,  $1. 00  net. 
In  Saunders'1  Question-  Compend  Scries. 

"  The  topics  are  treated  in  a  simple,  practical  manner,  and  the  work  forms  a  very  useful  student's 
manual." — Boston  Medical  and  Surgical  Journal. 

BrOCkway's    Medical    Physics.      Second  Edition,  Revised 

Essentials  of  Medical  Physics.  By  P'red.  J.  Brockway,  M.  D.,  late  Assistant 
Demonstrator  of  Anatomy,  College  of  Physicians  and  Surgeons,  N.  Y.  Post-octavo, 
330  pages  ;  155  fine  illustrations.  Cloth,  $1.00  net.  In  Saunders'  Question-Compend 
Series. 

"  It  contains  all  that  one  need  know  on  the  subject,  is  well  written,  and  is  copiously  illustrated." — 
Medical  Record,  New  York. 

Stoney's  Materia  Medica  for  Nurses 

Materia  Medica  for  Nurses.  By  the  late  Emii.y  A.  M.  Stoney,  Superintendent 
of  the  Training  School  for  Nurses,  Carney  Hospital,  South  Boston,  Mass.  Handsome 
octavo  volume  of  306  pages.      Cloth,  $1.50  net. 

"  It  contains  about  everything  that  a  nurse  ought  to  know  in  regard  to  drugs."— Journal  of  the 
American  Medical  Association. 

Grafstrom's  Mechano-therapy 

A  Text-Book  of  Mechano-therapy  (Massage  and  Medical  Gymnastics).  By 
Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  House  Physician,  City  Hospital,  Black- 
well's  Island,  N.  Y.      i2mo,  139  pages,  illustrated.     $1.00  net. 

"  Certainly  fulfills  its  mission  in  rendering  comprehensible  the  subjects  of  massage  and  medical 
gymnastics." — New    York  Medical  Journal. 


!6  SAUNDERS'    BOOKS   ON  PRACTICE,   Etc. 


Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

Atlas  and  Epitome  OF  Internal  Mkdicine  and  Clinical  Diagnosis.  By  Dr. 
Chr.  JAKOB,  of  Erlangen.  Edited,  with  additions,  by  A.  A.  Eshner,  M.  D.,  Pro- 
fessor of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  182  colored  figures  on 
68  plates,  64  text-illustrations,  259  pages  of  text.  Cloth,  #3.00  net.  In  Saunders' 
Hand-Atlas  Series. 

"  Can  be  recommended  unhesitatingly  to  the  practicing  physician  no  less  than  to  the  student."— 
Bulletin  of  Johns  Hopkins  Hospital. 

Lockwood's  Practice  of  Medicine.  RevkS?  and  Enlarged 

A  Manual  of  the  Practice  of  Medicine.  By  Geo.  Roe  Lockvvood,  M.  D., 
Attending  Physician  to  the  Bellevue  Hospital,  New  York  City.  Octavo,  847  pages, 
with  79  illustrations  in  the  text  and  22  full-page  plates.      Cloth,  #4.00  net. 

'•  A  work  of  positive  merit,  and  one  which  we  gladly  welcome." — New  York  Medical  Journal. 

Salinger  and  Kalteyer's  Modern  Medicine 

Modern  Medicine.  By  Julius  L.  Salinger,  M.  D.,  late  Demonstrate  of  Clinical 
Medicine,  Jefferson  Medical  College;  and  F.  J.  Kalteyek,  M.D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College.  Handsome  octavo,  801  pages,  illus- 
trated.    Cloth,  $4.00  net. 

"  I  have  carefully  examined  the  book,  and  find  it  to  be  thoroughly  trustworthy  in  all  respects  and  a 
valuable  text-book  for  the  medical  student." — Sam'l  O.  L.  Potter,  Formerly  Professor  of  Principles 
and  Practice  of  Medicine.  Cooper    Medical  College,  San  Francisco. 

Keating's  Life  Insurance 

How  to  Examine  for  Life  Insurance.  By  the  late  John  M.  Keating,  M.  D., 
Ex-President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal  octavo, 
211  pages.     With  numerous  illustrations.      Cloth,  #2.00  net. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination." — Medical 
News. 

Corwin's  Physical  Diagnosis.     Third  Edition,  Revised 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  A.  M.  Corwin,  A.  M., 
M.  D.,  Instructor  of  Physical  Diagnosis  in  Rush  Medical  College,  Chicago.  220 
pages,  illustrated.      Cloth,  flexible  covers,  $1.25  net. 

"  A  most  excellent  little  work.  It  arranges  orderly  and  in  sequence  the  various  objective  phenomena 
to  logical  solution  of  a  careful  diagnosis."— Journal  of  Nervous  and  Menial  Diseases. 

American  Text-Book  of  Theory  and  Practice 

American  Text-Book  of  the  Theory  and  Practice  of  Medicine.  Edited 
by  the  late  William  Pepper,  M.  D.,  LL.  D.,  Professor  of  the  Theory  and  Practice 
of  Medicine  and  of  Clinical  Medicine,  University  of  Penna.  Two  handsome  imperial 
octavos  of  about  1000  pages  each.  Illustrated.  Per  volume  :  Cloth,  £5.00  net ;  Sheep 
or  Half  Morocco,  $6.00  net. 

•'  I  am  quite  sure  it  will  command  itself  both  to  practitioners  and  students  of  medicine,  and  become 
one  of  our  most  popular  text-books."— Alfred  Loomis,  M.  D.,  LL,.  D.,  Professor  of  Pathology  and 
Practice  of  Medicine,  University  of  the   City  of  New   York. 

Stevens'  Practice  of  Medicine.     Fifth  Edition,  Revised 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M.,  M.  D., 
Lecturer  on  Physical  Diagnosis,  University  of  Pennsylvania.  Specially  intended  for 
students  preparing  for  graduation  and  hospital  examinations.  Post-octavo,  519  pages  ; 
illustrated.     Flexible  leather,  $2.00  net. 

"  An  excellent  condensation  of  the  essentials  of  medical  practice  for  the  student,  and  may  be  found 
also  an  excellent  reminder  for  the  busy  physician." — Buffalo  Medical  Journal. 


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